Healthcare Provider Details

I. General information

NPI: 1780977462
Provider Name (Legal Business Name): BROKEN BOW HEALTH AND REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 JONES ST.
BROKEN BOW OK
74728-0130
US

IV. Provider business mailing address

PO BOX 130 700 JONES ST.
BROKEN BOW OK
74728-0130
US

V. Phone/Fax

Practice location:
  • Phone: 580-584-6433
  • Fax: 580-584-2014
Mailing address:
  • Phone: 580-584-6433
  • Fax: 580-584-2014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH4501
License Number StateOK

VIII. Authorized Official

Name: MRS. GIELA RAYE WILLIAMS
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 580-584-6433