MEDICARE: TERRACE GARDENS NURSING CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	NH5535-5535	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174628721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TERRACE GARDENS NURSING CENTER, LLC

Provider Business Mailing Address
First Line	:	1921 NE 21ST ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-2420
Country	:	US
Telephone Number	:	405-424-1449
Fax Number	:	405-424-2004

Provider Business Practice Location Address
First Line	:	1921 NE 21ST ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-2420
Country	:	US
Telephone Number	:	405-424-1449
Fax Number	:	405-424-2004

Authorized Official
Title or Position	:	MANAGER
Name	:	MIKE DIMOND
Credential	:
Telephone Number	:	405-943-1144

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	03/23/2020

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