Provider Demographics
NPI:1144461476
Name:CORDOVA BAY LLC
Entity type:Organization
Organization Name:CORDOVA BAY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:VAHLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-329-4545
Mailing Address - Street 1:2411 SPRINGER DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-3955
Mailing Address - Country:US
Mailing Address - Phone:405-329-4545
Mailing Address - Fax:405-310-3371
Practice Address - Street 1:10207 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-4909
Practice Address - Country:US
Practice Address - Phone:806-712-1110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-17
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX012272251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX204233501Medicaid
TX457514OtherMEDICARE PROVIDER NUMBER