Healthcare Provider Details

I. General information

NPI: 1952758294
Provider Name (Legal Business Name): OK4 BROADWAY OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 E BROADWAY ST
MUSKOGEE OK
74403-4601
US

IV. Provider business mailing address

1622 E BROADWAY ST
MUSKOGEE OK
74403-4601
US

V. Phone/Fax

Practice location:
  • Phone: 918-683-2851
  • Fax:
Mailing address:
  • Phone: 918-683-2851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateOK

VIII. Authorized Official

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