Healthcare Provider Details

I. General information

NPI: 1376447318
Provider Name (Legal Business Name): QUAIL RIDGE LIVING CENTER OPERATING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 STATE LINE ROAD
COLCORD OK
74338
US

IV. Provider business mailing address

8520 S 36TH TER
FORT SMITH AR
72908-8880
US

V. Phone/Fax

Practice location:
  • Phone: 918-347-1042
  • Fax:
Mailing address:
  • Phone: 479-410-1740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ERIC DYKMAN
Title or Position: CORPORATE COMPLIANCE
Credential:
Phone: 228-875-5447