Healthcare Provider Details

I. General information

NPI: 1801918784
Provider Name (Legal Business Name): FAIR OAKS RESIDENTIAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 N 3RD ST
LANGLEY OK
74350
US

IV. Provider business mailing address

PO BOX 475
LANGLEY OK
74350-0475
US

V. Phone/Fax

Practice location:
  • Phone: 918-782-3180
  • Fax: 918-782-9715
Mailing address:
  • Phone: 918-782-3180
  • Fax: 918-782-9175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberRC4902-4902
License Number StateOK

VIII. Authorized Official

Name: DENISE WILSON
Title or Position: ADMINISTRATOR
Credential: LPN
Phone: 918-260-5422