MEDICARE: NRA ADA OKLAHOMA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	N/A	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	37D1049560	OTHER	OK	CLIA CERTIFICATE OF WAIVE

General Provider Information

NPI Number	:	1083651806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NRA ADA OKLAHOMA LLC

Provider Business Mailing Address
First Line	:	324 NW J A RICHARDSON LOOP
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-2017
Country	:	US
Telephone Number	:	580-421-9131
Fax Number	:	580-421-9135

Provider Business Practice Location Address
First Line	:	324 NW J.A. RICHARDSON LOOP
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-2017
Country	:	US
Telephone Number	:	580-421-9131
Fax Number	:	580-421-9135

Authorized Official
Title or Position	:	TREASURER
Name	:	MARK R FAWCETT
Credential	:
Telephone Number	:	781-699-9000

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	06/05/2014

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