Provider Demographics
NPI:1770557910
Name:RESTORE HOME HEALTHCARE OF OKLAHOMA ,LLC
Entity type:Organization
Organization Name:RESTORE HOME HEALTHCARE OF OKLAHOMA ,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CGO
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:LANIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-932-1852
Mailing Address - Street 1:6760 OLD JACKSONVILLE HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-0566
Mailing Address - Country:US
Mailing Address - Phone:903-363-9932
Mailing Address - Fax:888-333-8977
Practice Address - Street 1:4700 W URBANA ST STE 200
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5520
Practice Address - Country:US
Practice Address - Phone:918-682-9172
Practice Address - Fax:800-590-6996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7053251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
731398584016OtherBLUE CROSS BLUE SHIELD
OKHC7051OtherOKLAHOMA STATE DEPARTMENT OF HEALTH
OK100261100AMedicaid