Healthcare Provider Details

I. General information

NPI: 1053528026
Provider Name (Legal Business Name): GOLDEN VILLA CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EAST HARTFORD AVE.
PONCA CITY OK
74601
US

IV. Provider business mailing address

100 EAST HARTFORD AVE.
PONCA CITY OK
74601
US

V. Phone/Fax

Practice location:
  • Phone: 580-762-0264
  • Fax: 580-762-0420
Mailing address:
  • Phone: 580-762-0264
  • Fax: 580-762-0420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA R HOCKENBURY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 580-762-0264