Healthcare Provider Details

I. General information

NPI: 1083585491
Provider Name (Legal Business Name): FEDCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2025
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 N BROADWAY AVE
OKLAHOMA CITY OK
73103-3446
US

IV. Provider business mailing address

PO BOX 152
OKLAHOMA CITY OK
73101-0152
US

V. Phone/Fax

Practice location:
  • Phone: 405-219-2651
  • Fax: 405-429-5191
Mailing address:
  • Phone: 405-219-2651
  • Fax: 405-609-6679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: EMILI GRAGG
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 405-219-2651