Provider Demographics
NPI:1881438992
Name:OXFORD OUTPATIENT CENTER, LLC
Entity type:Organization
Organization Name:OXFORD OUTPATIENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OUTPATIENT OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, RN
Authorized Official - Phone:828-215-1455
Mailing Address - Street 1:1150 CHURCH RD W
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-7144
Mailing Address - Country:US
Mailing Address - Phone:662-205-0455
Mailing Address - Fax:
Practice Address - Street 1:1150 CHURCH RD W
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-7144
Practice Address - Country:US
Practice Address - Phone:662-205-0455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility