Healthcare Provider Details

I. General information

NPI: 1124848205
Provider Name (Legal Business Name): GOLD TEAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9210 S WESTERN AVE STE A21
OKLAHOMA CITY OK
73139-4982
US

IV. Provider business mailing address

9210 S WESTERN AVE STE A21
OKLAHOMA CITY OK
73139-4982
US

V. Phone/Fax

Practice location:
  • Phone: 678-777-8038
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name: STANLEY NZUONKWELLE
Title or Position: CEO
Credential:
Phone: 678-777-8038