MEDICARE: SWEET TOWN, 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	313M00000X	Nursing Facility/Intermediate Care Facility	NH5901-5901	OK

General Provider Information

NPI Number	:	1194805556
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SWEET TOWN, LLC

Provider Business Mailing Address
First Line	:	PO BOX 9
Second Line	:
City	:	SALLISAW
State	:	OK
Zip	:	74955-0009
Country	:	US
Telephone Number	:	918-776-0033
Fax Number	:	918-776-0220

Provider Business Practice Location Address
First Line	:	900 N DIVISION ST
Second Line	:
City	:	CLEVELAND
State	:	OK
Zip	:	74020-1222
Country	:	US
Telephone Number	:	918-358-3135
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	MELINDA MARTIN
Credential	:
Telephone Number	:	918-776-0033

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	08/22/2020

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