MEDICARE: DANIEL CERQUITELLA

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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1134586084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL CERQUITELLA

Provider Business Mailing Address
First Line	:	3243 NW 22ND ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73107-3019
Country	:	US
Telephone Number	:	405-550-6134
Fax Number	:

Provider Business Practice Location Address
First Line	:	3243 NW 22ND ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73107-3019
Country	:	US
Telephone Number	:	405-550-6134
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2016
Last Update Date	:	01/23/2016

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