Provider Demographics
NPI:1386625622
Name:AUTUMN BRIDGE, LLC
Entity Type:Organization
Organization Name:AUTUMN BRIDGE, LLC
Other - Org Name:NEW CENTURY HOSPICE OF OKLAHOMA CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF LEGAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-662-0414
Mailing Address - Street 1:655 BRAWLEY SCHOOL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9601
Mailing Address - Country:US
Mailing Address - Phone:704-664-2876
Mailing Address - Fax:704-664-1306
Practice Address - Street 1:3500 NW 39TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112
Practice Address - Country:US
Practice Address - Phone:405-440-2440
Practice Address - Fax:405-440-2441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4181251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000371633001OtherBC/BS PROVIDER NUMBER
371633Medicare Oscar/Certification