1396279808 NPI number — TEAL CREEK LIFE CARE COMMUNITY INC

Table of content: (NPI 1396279808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396279808 NPI number — TEAL CREEK LIFE CARE COMMUNITY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEAL CREEK LIFE CARE COMMUNITY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396279808
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13501 N. BRYANT AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-312-8050
Provider Business Mailing Address Fax Number:
866-542-6483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13501 N. BRYANT AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-312-8050
Provider Business Practice Location Address Fax Number:
866-542-6483
Provider Enumeration Date:
04/12/2017

Additional Information

Authorized Official

Authorized Official Last Name:
GUYMON
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
LANCE
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
405-312-8050

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL5541 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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