1154310399 NPI number — POTEAU NURSING CENTER, LLC

Table of content: (NPI 1154310399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154310399 NPI number — POTEAU NURSING CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POTEAU NURSING CENTER, 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:
Provider Other Organization Name Type Code:
6
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:
1154310399
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1805 E 15TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74104-4610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-622-4799
Provider Business Mailing Address Fax Number:
918-622-4798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 CLAYTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POTEAU
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74953-4102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-647-8236
Provider Business Practice Location Address Fax Number:
918-649-3747
Provider Enumeration Date:
10/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LIETZKE
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
918-622-4799

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH40094009 , 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: 100847080A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000375166001 . This is a "BC/BS PROVIDEDR ID" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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