MEDICARE: GIOVANA PORTUGAL MASTERS

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1578882692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GIOVANA PORTUGAL MASTERS

Provider Business Mailing Address
First Line	:	225 S WARDS CHAPEL
Second Line	:
City	:	ATOKA
State	:	OK
Zip	:	74525-4104
Country	:	US
Telephone Number	:	580-380-1844
Fax Number	:

Provider Business Practice Location Address
First Line	:	1021 SW 128TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-6951
Country	:	US
Telephone Number	:	405-626-4418
Fax Number	:

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

Provider Enumeration Date	:	05/28/2010
Last Update Date	:	05/28/2010

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Directions to “ GIOVANA PORTUGAL MASTERS” Practice Location

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