MEDICARE: OAC MANAGEMENT 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	261QM1300X	Multi-Specialty Clinic/Center		VA

General Provider Information

NPI Number	:	1942582036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAC MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	3454 STONE MOUNTAIN LN
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84092-6549
Country	:	US
Telephone Number	:	801-688-7441
Fax Number	:

Provider Business Practice Location Address
First Line	:	5589 GREENWICH RD
Second Line	:	SUITE 175
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-6565
Country	:	US
Telephone Number	:	757-216-9115
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	DERK PARDOE
Credential	:
Telephone Number	:	801-808-2357

Provider Enumeration Date	:	09/14/2011
Last Update Date	:	02/15/2012

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