MEDICARE: THE FAMILY CARE CENTER OF HARRAH, INC.

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	207Q00000X	Family Medicine Physician
2	261QP2300X	Primary Care Clinic/Center	2323	OK

General Provider Information

NPI Number	:	1801840368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE FAMILY CARE CENTER OF HARRAH, INC.

Provider Business Mailing Address
First Line	:	PO BOX 900
Second Line	:
City	:	HARRAH
State	:	OK
Zip	:	73045-0900
Country	:	US
Telephone Number	:	405-454-2404
Fax Number	:	405-454-6372

Provider Business Practice Location Address
First Line	:	20826 MAIN ST
Second Line	:
City	:	HARRAH
State	:	OK
Zip	:	73045-9755
Country	:	US
Telephone Number	:	405-454-2404
Fax Number	:	405-454-6372

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. LEN U LACEFIELD JR.
Credential	:
Telephone Number	:	405-454-2404

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	04/24/2008

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