=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871908913
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDMOND MEMORY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2014
-----------------------------------------------------
Last Update Date | 06/27/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 S BRYANT AVE
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73034-5745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-341-1450
-----------------------------------------------------
Fax | 405-341-1451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 545 E JOHN CARPENTER FWY SUITE 500
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75062-3931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-845-4500
-----------------------------------------------------
Fax | 214-845-4501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF MANAGEMENT-SENIOR LIVING
-----------------------------------------------------
Name | CHRISTOPHER RIO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-845-4500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL5598-5598
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------