MEDICARE: MRS. OPHETTA MALCOLM

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1386218667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. OPHETTA MALCOLM

Provider Business Mailing Address
First Line	:	1018 E 11TH ST
Second Line	:
City	:	CUSHING
State	:	OK
Zip	:	74023-5204
Country	:	US
Telephone Number	:	203-644-7920
Fax Number	:

Provider Business Practice Location Address
First Line	:	4500 N LINCOLN BLVD STE 105
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73105-3406
Country	:	US
Telephone Number	:	203-644-7920
Fax Number	:

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

Provider Enumeration Date	:	05/19/2021
Last Update Date	:	05/19/2021

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