Provider Demographics
NPI:1083854798
Name:WOVENLIFE, INC.
Entity Type:Organization
Organization Name:WOVENLIFE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:KRISTIN
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-239-2525
Mailing Address - Street 1:701 NE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5003
Mailing Address - Country:US
Mailing Address - Phone:405-239-2525
Mailing Address - Fax:405-239-2278
Practice Address - Street 1:701 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5003
Practice Address - Country:US
Practice Address - Phone:405-239-2525
Practice Address - Fax:405-239-2278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-20
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 261QM2500X
OKDC5512261QA0600X
OKDC5512-5512385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100683310AMedicaid
OK100683310BMedicaid