Healthcare Provider Details

I. General information

NPI: 1114002987
Provider Name (Legal Business Name): OAK PLACE LIVING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E 2ND ST
WETUMKA OK
74883-6040
US

IV. Provider business mailing address

PO BOX 488
WELEETKA OK
74880-0488
US

V. Phone/Fax

Practice location:
  • Phone: 405-452-3271
  • Fax: 405-452-5154
Mailing address:
  • Phone: 405-786-2266
  • Fax: 405-786-2388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License NumberNH3213-3213
License Number StateOK

VIII. Authorized Official

Name: MRS. DONNA R SIMMONS
Title or Position: OFFICE MANAGER
Credential:
Phone: 405-380-6671