Healthcare Provider Details

I. General information

NPI: 1184059982
Provider Name (Legal Business Name): AUTUMN WOOD OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 N HICKORY ST
CLAREMORE OK
74017-1214
US

IV. Provider business mailing address

2700 N HICKORY ST
CLAREMORE OK
74017-1214
US

V. Phone/Fax

Practice location:
  • Phone: 918-283-4949
  • Fax: 918-283-4508
Mailing address:
  • Phone: 918-283-4949
  • Fax: 918-283-4508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberNH6609
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number375553
License Number StateOK

VIII. Authorized Official

Name: THERESA MERE
Title or Position: ASSOCIATE
Credential:
Phone: 325-691-5591