MEDICARE: CHECOTAH HOLDINGS, 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	3140N1450X	Pediatric Skilled Nursing Facility	313M00000X	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	:	1992778278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHECOTAH HOLDINGS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 429
Second Line	:
City	:	CHECOTAH
State	:	OK
Zip	:	74426-0429
Country	:	US
Telephone Number	:	918-473-2251
Fax Number	:

Provider Business Practice Location Address
First Line	:	321 SE 2ND ST
Second Line	:
City	:	CHECOTAH
State	:	OK
Zip	:	74426-4005
Country	:	US
Telephone Number	:	918-473-2251
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. DEBORAH K KELSOE
Credential	:
Telephone Number	:	918-473-5598

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	08/22/2020

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