Healthcare Provider Details

I. General information

NPI: 1982938072
Provider Name (Legal Business Name): LEGEND AT JEFFERSON'S GARDEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15401 N PENNSYLVANIA AVE
EDMOND OK
73013
US

IV. Provider business mailing address

15401 N PENNSYLVANIA AVE
EDMOND OK
73013
US

V. Phone/Fax

Practice location:
  • Phone: 405-715-1717
  • Fax: 405-715-9017
Mailing address:
  • Phone: 405-715-1717
  • Fax: 405-715-9017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License NumberAL5517-5517
License Number StateOK

VIII. Authorized Official

Name: MRS. NELDA RANDALL
Title or Position: DIRECTOR
Credential:
Phone: 405-715-1717