Provider Demographics
NPI:1851487508
Name:EDWARDS REDEEMER NURSING CENTER, LLC
Entity Type:Organization
Organization Name:EDWARDS REDEEMER NURSING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-786-2266
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:WELEETKA
Mailing Address - State:OK
Mailing Address - Zip Code:74880-0488
Mailing Address - Country:US
Mailing Address - Phone:405-786-2266
Mailing Address - Fax:405-786-2388
Practice Address - Street 1:1530 NE GRAND BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-5212
Practice Address - Country:US
Practice Address - Phone:405-424-2273
Practice Address - Fax:405-424-2070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5549-5549314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
375339Medicare ID - Type Unspecified