Healthcare Provider Details

I. General information

NPI: 1598354276
Provider Name (Legal Business Name): OPCO COWETA, OK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30049 E 151ST ST S
COWETA OK
74429-4544
US

IV. Provider business mailing address

2045 W GRAND AVE STE B34572
CHICAGO IL
60612-1576
US

V. Phone/Fax

Practice location:
  • Phone: 918-486-2166
  • Fax:
Mailing address:
  • Phone: 312-724-8950
  • Fax:

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: ISAAC DOLE
Title or Position: MANAGER
Credential:
Phone: 773-645-9246