Provider Demographics
NPI:1679351704
Name:SOUL SURVIVOR SUPPORTIVE LIVING FDN
Entity Type:Organization
Organization Name:SOUL SURVIVOR SUPPORTIVE LIVING FDN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPEED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-863-5578
Mailing Address - Street 1:PO BOX 932
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-0932
Mailing Address - Country:US
Mailing Address - Phone:405-863-5578
Mailing Address - Fax:
Practice Address - Street 1:3612 OAK GROVE DR
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-3728
Practice Address - Country:US
Practice Address - Phone:405-863-5578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility