Healthcare Provider Details

I. General information

NPI: 1013916311
Provider Name (Legal Business Name): SOUTHBROOK HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 ISABEL ST
ARDMORE OK
73401-5118
US

IV. Provider business mailing address

832 ISABEL ST
ARDMORE OK
73401-5118
US

V. Phone/Fax

Practice location:
  • Phone: 580-223-5901
  • Fax: 580-226-0841
Mailing address:
  • Phone: 580-223-5901
  • Fax: 580-226-0841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH1006-1006
License Number StateOK

VIII. Authorized Official

Name: MR. TOM C COBLE
Title or Position: OWNER
Credential:
Phone: 580-226-3055