MEDICARE: DARBY GRACE HEATH CSFA

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	246ZC0007X	Surgical Assistant	221720

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	221720	OTHER		NBSTSA

General Provider Information

NPI Number	:	1619756574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARBY GRACE HEATH CSFA

Provider Business Mailing Address
First Line	:	6600 NW 63RD ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73132-7205
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6600 NW 63RD ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73132-7205
Country	:	US
Telephone Number	:	405-783-3004
Fax Number	:

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

Provider Enumeration Date	:	09/28/2023
Last Update Date	:	09/28/2023

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