Healthcare Provider Details

I. General information

NPI: 1912104670
Provider Name (Legal Business Name): MRS. LORI FAY ONEILL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 WEST SOUTH AVE
VINITA OK
74301
US

IV. Provider business mailing address

321 WEST SOUTH AVE
VINITA OK
74301
US

V. Phone/Fax

Practice location:
  • Phone: 918-256-5499
  • Fax: 918-256-8861
Mailing address:
  • Phone: 918-256-5499
  • Fax: 918-256-8861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: