Healthcare Provider Details

I. General information

NPI: 1306243019
Provider Name (Legal Business Name): GREEN COUNTRY REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 NW 58TH ST STE 940
OKLAHOMA CITY OK
73112-4802
US

IV. Provider business mailing address

3535 NW 58TH ST STE 940
OKLAHOMA CITY OK
73112-4802
US

V. Phone/Fax

Practice location:
  • Phone: 405-605-1130
  • Fax: 405-605-1402
Mailing address:
  • Phone: 405-605-1130
  • Fax: 405-605-1402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number597
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number597
License Number StateOK

VIII. Authorized Official

Name: MRS. TERRI LYNN- HARRIS DAVIS
Title or Position: COTA/L
Credential: COTA/L
Phone: 405-517-8198