Healthcare Provider Details

I. General information

NPI: 1235348442
Provider Name (Legal Business Name): GREENBRIER VILLAGE ADULT DAY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 E OWEN K GARRIOTT RD SUITE 216
ENID OK
73701-6235
US

IV. Provider business mailing address

1217 E OWEN K GARRIOTT RD SUITE 216
ENID OK
73701-6235
US

V. Phone/Fax

Practice location:
  • Phone: 580-234-5827
  • Fax:
Mailing address:
  • Phone: 580-234-5827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberDC2404-2404
License Number StateOK

VIII. Authorized Official

Name: MR. HERMAN F HACKETT
Title or Position: OWNER
Credential:
Phone: 580-233-0121