MEDICARE: OKLAHOMA PET CENTER 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	261QR0200X	Radiology Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	569959716001	OTHER	OK	BCBS

General Provider Information

NPI Number	:	1477739662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OKLAHOMA PET CENTER LLC

Provider Business Mailing Address
First Line	:	5401 N PORTLAND AVE
Second Line	:	330
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-2121
Country	:	US
Telephone Number	:	405-604-4439
Fax Number	:

Provider Business Practice Location Address
First Line	:	5401 N PORTLAND AVE
Second Line	:	330
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-2121
Country	:	US
Telephone Number	:	405-604-4439
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GEORGE N CHACKO
Credential	:	MD
Telephone Number	:	405-604-4439

Provider Enumeration Date	:	01/17/2008
Last Update Date	:	01/17/2008

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Directions to “OKLAHOMA PET CENTER LLC ” Practice Location

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