MEDICARE: WAYNOKA NURSING CENTER AUTHORITY

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	NH7603-7603	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	:	1316059645
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAYNOKA NURSING CENTER AUTHORITY

Provider Business Mailing Address
First Line	:	2601 BROADWAY ST
Second Line	:
City	:	WAYNOKA
State	:	OK
Zip	:	73860-6812
Country	:	US
Telephone Number	:	580-824-5661
Fax Number	:	580-824-5662

Provider Business Practice Location Address
First Line	:	2601 BROADWAY ST
Second Line	:
City	:	WAYNOKA
State	:	OK
Zip	:	73860-6812
Country	:	US
Telephone Number	:	580-824-5661
Fax Number	:	580-824-5662

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	TOM LEATHERMAN
Credential	:
Telephone Number	:	580-824-5661

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	01/31/2012

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Directions to “WAYNOKA NURSING CENTER AUTHORITY ” Practice Location

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