Healthcare Provider Details

I. General information

NPI: 1902473945
Provider Name (Legal Business Name): OKC HOMEDIALYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 N CLASSEN BLVD STE 105
OKLAHOMA CITY OK
73118-2668
US

IV. Provider business mailing address

3727 NW 63RD ST STE 300
OKLAHOMA CITY OK
73116-1923
US

V. Phone/Fax

Practice location:
  • Phone: 580-695-1306
  • Fax: 405-217-0010
Mailing address:
  • Phone: 405-286-0576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LESLIE A WHILES
Title or Position: FA
Credential: ADMINISTRATOR
Phone: 580-695-1306