Healthcare Provider Details

I. General information

NPI: 1528336252
Provider Name (Legal Business Name): AWENASA MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 E CONNER AVE.
FAIRLAND OK
74343-0336
US

IV. Provider business mailing address

5430 W 640
CHOUTEAU OK
74337-5504
US

V. Phone/Fax

Practice location:
  • Phone: 918-676-3685
  • Fax: 918-676-3008
Mailing address:
  • Phone: 918-476-6642
  • Fax: 918-476-4679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. TERESA MAHURIN
Title or Position: MANAGING MEMBER
Credential:
Phone: 918-476-6642