MEDICARE: NORTH CENTRAL PALLIATIVE CARE, 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	207RH0002X	Hospice and Palliative Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1821505900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH CENTRAL PALLIATIVE CARE, LLC

Provider Business Mailing Address
First Line	:	445 FAIRVIEW AVE
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-1931
Country	:	US
Telephone Number	:	580-762-9102
Fax Number	:	580-762-9111

Provider Business Practice Location Address
First Line	:	445 FAIRVIEW AVE
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-1931
Country	:	US
Telephone Number	:	580-762-9102
Fax Number	:	580-762-1911

Authorized Official
Title or Position	:	ATTORNEY
Name	:	RACHEL JORDAN
Credential	:
Telephone Number	:	405-234-3220

Provider Enumeration Date	:	01/10/2018
Last Update Date	:	01/10/2018

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