MEDICARE: NNA OF 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

General Provider Information

NPI Number	:	1386756252
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NNA OF OKLAHOMA LLC

Provider Business Mailing Address
First Line	:	1402 BROOKVIEW DR
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-1219
Country	:	US
Telephone Number	:	580-226-9390
Fax Number	:	580-226-4555

Provider Business Practice Location Address
First Line	:	1402 BROOKVIEW DR
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-1219
Country	:	US
Telephone Number	:	580-226-9390
Fax Number	:	580-226-4555

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/06/2009

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Directions to “NNA OF OKLAHOMA LLC ” Practice Location

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