Healthcare Provider Details

I. General information

NPI: 1063517704
Provider Name (Legal Business Name): WYNNEWOOD NURSING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 E CALIFORNIA ST
WYNNEWOOD OK
73098-3207
US

IV. Provider business mailing address

810 E CALIFORNIA ST
WYNNEWOOD OK
73098-3207
US

V. Phone/Fax

Practice location:
  • Phone: 405-665-2330
  • Fax: 405-665-4378
Mailing address:
  • Phone: 405-665-2330
  • Fax: 405-665-4378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH2506-2506
License Number StateOK

VIII. Authorized Official

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