MEDICARE: SOONER GERIATRICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	NH5501-5501	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164527727
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOONER GERIATRICS, LLC

Provider Business Mailing Address
First Line	:	1921 NE 50TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-2420
Country	:	US
Telephone Number	:	405-427-5414
Fax Number	:	405-427-5432

Provider Business Practice Location Address
First Line	:	1913 NE 50TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-7003
Country	:	US
Telephone Number	:	405-427-5414
Fax Number	:	405-427-5432

Authorized Official
Title or Position	:	DIRECTOR OF REIMBURSEMENT
Name	:	KRISTY DEROIN
Credential	:
Telephone Number	:	405-943-1144

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	02/06/2026

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