Healthcare Provider Details

I. General information

NPI: 1548455975
Provider Name (Legal Business Name): IHS WYNNEWOOD CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 N BROADWAY AVE
ADA OK
74820-5003
US

IV. Provider business mailing address

810 E CALIFORNIA ST
WYNNEWOOD OK
73098-3207
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-0950
  • Fax: 580-436-0953
Mailing address:
  • Phone: 405-665-2330
  • Fax: 405-943-4917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH2506-2506
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH2506-2506
License Number StateOK

VIII. Authorized Official

Name: MR. BART TAYLOR REED
Title or Position: PRESIDENT
Credential:
Phone: 580-436-0950