Provider Demographics
NPI:1801918784
Name:FAIR OAKS RESIDENTIAL CARE LLC
Entity type:Organization
Organization Name:FAIR OAKS RESIDENTIAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:918-260-5422
Mailing Address - Street 1:PO BOX 475
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:OK
Mailing Address - Zip Code:74350-0475
Mailing Address - Country:US
Mailing Address - Phone:918-782-3180
Mailing Address - Fax:918-782-9175
Practice Address - Street 1:1330 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LANGLEY
Practice Address - State:OK
Practice Address - Zip Code:74350
Practice Address - Country:US
Practice Address - Phone:918-782-3180
Practice Address - Fax:918-782-9715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRC4902-49023104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness