Provider Demographics
NPI:1255477030
Name:GRACE HOSPICE OF OKLAHOMA LLC
Entity Type:Organization
Organization Name:GRACE HOSPICE OF OKLAHOMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:EVERSOLE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:918-744-7223
Mailing Address - Street 1:PO BOX 33234
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74153-1234
Mailing Address - Country:US
Mailing Address - Phone:918-744-7223
Mailing Address - Fax:918-744-8310
Practice Address - Street 1:6218 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1018
Practice Address - Country:US
Practice Address - Phone:918-744-7223
Practice Address - Fax:918-744-5784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4137251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK371595Medicare ID - Type Unspecified