MEDICARE: 5TH STREET SNF OPERATIONS 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

General Provider Information

NPI Number	:	1235085879
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	5TH STREET SNF OPERATIONS LLC

Provider Business Mailing Address
First Line	:	10913 S RIVER FRONT PKWY STE 290
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-3507
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 W 5TH ST
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-3415
Country	:	US
Telephone Number	:	580-436-1414
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	BRIAN RAMOS
Credential	:
Telephone Number	:	580-436-1414

Provider Enumeration Date	:	03/06/2026
Last Update Date	:	03/06/2026

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Directions to “5TH STREET SNF OPERATIONS LLC ” Practice Location

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