MEDICARE: CACEE REUBEN ATC

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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1942689922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CACEE REUBEN ATC

Provider Business Mailing Address
First Line	:	3401 N MAY AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-6904
Country	:	US
Telephone Number	:	405-858-0097
Fax Number	:	405-858-0119

Provider Business Practice Location Address
First Line	:	3401 N MAY AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-6904
Country	:	US
Telephone Number	:	405-858-0097
Fax Number	:	405-858-0119

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

Provider Enumeration Date	:	05/25/2015
Last Update Date	:	05/25/2015

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