1003815796 NPI number — N& R OF PONCA CITY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003815796 NPI number — N& R OF PONCA CITY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
N& R OF PONCA CITY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PONCA CITY NURSING AND REHAB
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003815796
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
329 TOWNEPARK CIR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40243-2348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-254-9525
Provider Business Mailing Address Fax Number:
502-254-9919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 N WAVERLY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PONCA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74601-2134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-762-6668
Provider Business Practice Location Address Fax Number:
580-762-2669
Provider Enumeration Date:
07/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TRUMBO
Authorized Official First Name:
JAY
Authorized Official Middle Name:
H
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
502-254-9525

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH3606-3606 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100849730A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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