Healthcare Provider Details

I. General information

NPI: 1164527727
Provider Name (Legal Business Name): SOONER GERIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1913 NE 50TH ST
OKLAHOMA CITY OK
73111-7003
US

IV. Provider business mailing address

1921 NE 50TH ST
OKLAHOMA CITY OK
73111-2420
US

V. Phone/Fax

Practice location:
  • Phone: 405-427-5414
  • Fax: 405-427-5432
Mailing address:
  • Phone: 405-427-5414
  • Fax: 405-427-5432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH5501-5501
License Number StateOK

VIII. Authorized Official

Name: KRISTY DEROIN
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 405-943-1144