Provider Demographics
NPI:1306213293
Name:LIMITED LIABILITY CORPORATION
Entity type:Organization
Organization Name:LIMITED LIABILITY CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:D
Authorized Official - Last Name:OVERLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-915-7245
Mailing Address - Street 1:17105 BETHEL RD STE A
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-2938
Mailing Address - Country:US
Mailing Address - Phone:405-915-7245
Mailing Address - Fax:844-272-8001
Practice Address - Street 1:8524 S WESTERN AVE STE 109
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9247
Practice Address - Country:US
Practice Address - Phone:405-915-7245
Practice Address - Fax:405-913-1200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-26
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251G00000X, 305S00000X
OKH04302251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
No305S00000XManaged Care OrganizationsPoint of Service