MEDICARE: CRYSTAL JAYROE RAYMOND

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
2	171W00000X	Contractor

General Provider Information

NPI Number	:	1407102478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL JAYROE RAYMOND

Provider Business Mailing Address
First Line	:	11212 N MAY AVE STE 208
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-6335
Country	:	US
Telephone Number	:	405-708-6331
Fax Number	:

Provider Business Practice Location Address
First Line	:	11212 N MAY AVE STE 208
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-6335
Country	:	US
Telephone Number	:	405-708-6331
Fax Number	:

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

Provider Enumeration Date	:	07/27/2012
Last Update Date	:	07/27/2012

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