Healthcare Provider Details

I. General information

NPI: 1154944940
Provider Name (Legal Business Name): VILLAGE BA OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 S MAIN ST
BROKEN ARROW OK
74012-6502
US

IV. Provider business mailing address

PO BOX 990
EDMOND OK
73083-0990
US

V. Phone/Fax

Practice location:
  • Phone: 405-285-8166
  • Fax:
Mailing address:
  • Phone: 405-285-8166
  • Fax: 405-563-9447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SCOTT PILGRIM
Title or Position: MEMBER
Credential:
Phone: 405-285-8166