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General NPI Number Information
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NPI Number | 1982938072
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Entity Type | Organization
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Legal Business Name | LEGEND AT JEFFERSON'S GARDEN
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Dates
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Enumeration Date | 09/23/2009
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Last Update Date | 09/23/2009
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Provider Practice Location Address
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Address Line | 15401 N PENNSYLVANIA AVE
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City | EDMOND
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State | OK
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Zip | 73013
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Country | US
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Telephone | 405-715-1717
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Fax | 405-715-9017
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Provider Business Mailing Address
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Address Line | 15401 N PENNSYLVANIA AVE
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City | EDMOND
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State | OK
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Zip | 73013
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Country | US
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Telephone | 405-715-1717
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Fax | 405-715-9017
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. NELDA RANDALL
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Credential |
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Telephone | 405-715-1717
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320700000X
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Taxonomy Name | Physical Disabilities Residential Treatment Facility
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License Number | AL5517-5517
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License Number State | OK
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