Provider Demographics
NPI:1184059982
Name:AUTUMN WOOD OPCO, LLC
Entity type:Organization
Organization Name:AUTUMN WOOD OPCO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-691-5591
Mailing Address - Street 1:2700 N HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-1214
Mailing Address - Country:US
Mailing Address - Phone:918-283-4949
Mailing Address - Fax:918-283-4508
Practice Address - Street 1:2700 N HICKORY ST
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-1214
Practice Address - Country:US
Practice Address - Phone:918-283-4949
Practice Address - Fax:918-283-4508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH6609311500000X
OK375553314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200478150AMedicaid
OK375553Medicare Oscar/Certification