1437146529 NPI number — SHADY REST CARE CENTER, LLC

Table of content: (NPI 1437146529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437146529 NPI number — SHADY REST CARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHADY REST CARE 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:
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:
1437146529
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1505 W CHICKASAW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALLISAW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74955-7201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-775-6200
Provider Business Mailing Address Fax Number:
918-775-5643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 S ADAIR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRYOR
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74361-5202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-825-4455
Provider Business Practice Location Address Fax Number:
918-825-8493
Provider Enumeration Date:
10/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
VP IN CHARGE OF REIMBURSEMENT
Authorized Official Telephone Number:
918-775-6200

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  314000000X , 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: 100777350A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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