MEDICARE: GRACIE ROGERS

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	171M00000X	Case Manager/Care Coordinator		OK

General Provider Information

NPI Number	:	1902189822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACIE ROGERS

Provider Business Mailing Address
First Line	:	5113 SE 47TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5113 SE 47TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-4143
Country	:	US
Telephone Number	:	405-473-6067
Fax Number	:

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

Provider Enumeration Date	:	09/27/2011
Last Update Date	:	09/27/2011

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