Healthcare Provider Details

I. General information

NPI: 1144461476
Provider Name (Legal Business Name): CORDOVA BAY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2009
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10207 INDIANA AVE
LUBBOCK TX
79423-4909
US

IV. Provider business mailing address

2411 SPRINGER DR
NORMAN OK
73069-3955
US

V. Phone/Fax

Practice location:
  • Phone: 806-712-1110
  • Fax:
Mailing address:
  • Phone: 405-329-4545
  • Fax: 405-310-3371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number012272
License Number StateTX

VIII. Authorized Official

Name: MRS. KAREN ELAINE VAHLBERG
Title or Position: CEO
Credential:
Phone: 405-329-4545