Healthcare Provider Details

I. General information

NPI: 1528163391
Provider Name (Legal Business Name): NORTHWEST INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3233 NW 10TH ST
OKLAHOMA CITY OK
73107-5203
US

IV. Provider business mailing address

3233 NW 10TH ST
OKLAHOMA CITY OK
73107-5203
US

V. Phone/Fax

Practice location:
  • Phone: 405-943-8366
  • Fax: 405-488-0100
Mailing address:
  • Phone: 405-943-8366
  • Fax: 405-488-0100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH5511-5511
License Number StateOK

VIII. Authorized Official

Name: MIKE DIMOND
Title or Position: MANAGER
Credential:
Phone: 405-943-1144