MEDICARE: QUAIL RIDGE SENIOR DEVELOPMENT, 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	310400000X	Assisted Living Facility	AL5523-5523	OK

General Provider Information

NPI Number	:	1497944292
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUAIL RIDGE SENIOR DEVELOPMENT, LLC

Provider Business Mailing Address
First Line	:	12401 TRAIL OAKS DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-1701
Country	:	US
Telephone Number	:	405-755-5775
Fax Number	:	405-749-9324

Provider Business Practice Location Address
First Line	:	12401 TRAIL OAKS DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-1701
Country	:	US
Telephone Number	:	405-755-5775
Fax Number	:	405-749-9324

Authorized Official
Title or Position	:	MANAGING OWNER
Name	:	MR. DAVID SMITH
Credential	:
Telephone Number	:	405-755-5775

Provider Enumeration Date	:	10/17/2007
Last Update Date	:	10/17/2007

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