Provider Demographics
NPI:1548455975
Name:IHS WYNNEWOOD CARE CENTER LLC
Entity type:Organization
Organization Name:IHS WYNNEWOOD CARE CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BART
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-436-0950
Mailing Address - Street 1:810 E CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:OK
Mailing Address - Zip Code:73098-3207
Mailing Address - Country:US
Mailing Address - Phone:405-665-2330
Mailing Address - Fax:405-943-4917
Practice Address - Street 1:131 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-5003
Practice Address - Country:US
Practice Address - Phone:580-436-0950
Practice Address - Fax:580-436-0953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH2506-2506314000000X, 313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1007767770AMedicaid
OK375176Medicare Oscar/Certification