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General NPI Number Information
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NPI Number | 1104174267
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Entity Type | Organization
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Legal Business Name | FIDELIS ONE LLC
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Dates
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Enumeration Date | 08/21/2012
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Last Update Date | 08/24/2012
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Provider Practice Location Address
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Address Line | 4825 NW 23RD ST
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City | OKLAHOMA CITY
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State | OK
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Zip | 73127
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Country | US
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Telephone | 405-945-0010
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Fax | 405-947-6542
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Provider Business Mailing Address
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Address Line | 4601 N CLASSEN BLVD
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City | OKLAHOMA CITY
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State | OK
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Zip | 73118
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Country | US
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Telephone | 405-840-9991
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Fax | 405-840-9998
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | SHANTHARAM DARBE
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Credential |
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Telephone | 405-840-9991
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL5516
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License Number State | OK
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