Provider Demographics
NPI:1114922598
Name:CENTRAL OKLAHOMA UNITED METHODIST RETIREMENT FACILITY INC
Entity Type:Organization
Organization Name:CENTRAL OKLAHOMA UNITED METHODIST RETIREMENT FACILITY INC
Other - Org Name:EPWORTH VILLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-749-3516
Mailing Address - Street 1:14901 N PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-6069
Mailing Address - Country:US
Mailing Address - Phone:405-752-1200
Mailing Address - Fax:405-755-5106
Practice Address - Street 1:14901 N PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134
Practice Address - Country:US
Practice Address - Phone:405-752-1200
Practice Address - Fax:405-755-5106
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EPWORTH LIVING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-14
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKCC5504313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375473Medicare ID - Type Unspecified