Healthcare Provider Details

I. General information

NPI: 1164940029
Provider Name (Legal Business Name): CITY OF SAPULPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 08/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17110 E 51ST ST
BROKEN ARROW OK
74012-9279
US

IV. Provider business mailing address

PO BOX 990
EDMOND OK
73083-0990
US

V. Phone/Fax

Practice location:
  • Phone: 918-355-1596
  • Fax: 918-355-3201
Mailing address:
  • Phone: 405-285-8166
  • Fax: 405-563-9447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberCCRC7202
License Number StateOK

VIII. Authorized Official

Name: BILL BUSH
Title or Position: CFO
Credential:
Phone: 405-285-8166