Provider Demographics
NPI:1528336252
Name:AWENASA MANAGEMENT LLC
Entity type:Organization
Organization Name:AWENASA MANAGEMENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHURIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-476-6642
Mailing Address - Street 1:5430 W 640
Mailing Address - Street 2:
Mailing Address - City:CHOUTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74337-5504
Mailing Address - Country:US
Mailing Address - Phone:918-476-6642
Mailing Address - Fax:918-476-4679
Practice Address - Street 1:12 E CONNER AVE.
Practice Address - Street 2:
Practice Address - City:FAIRLAND
Practice Address - State:OK
Practice Address - Zip Code:74343-0336
Practice Address - Country:US
Practice Address - Phone:918-676-3685
Practice Address - Fax:918-676-3008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK37E258Medicaid
37-5515OtherMEDICARE CCN