Basic Information
| Provider Information | |||||||||
| NPI: | 1902054059 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRYANT HEALTHCARE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARE LIVING CENTER OF EDMOND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1380 S DOUGLAS BLVD | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731305215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057372106 | ||||||||
| FaxNumber: | 4057370899 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 E 9TH ST | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730345705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053415617 | ||||||||
| FaxNumber: | 4053411792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2008 | ||||||||
| LastUpdateDate: | 09/03/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NARULA | ||||||||
| AuthorizedOfficialFirstName: | RAJ | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECT OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4057372106 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.