Healthcare Provider Details

I. General information

NPI: 1821182270
Provider Name (Legal Business Name): WESTERN NURSING HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 WALNUT DR
BUFFALO OK
73834
US

IV. Provider business mailing address

111 WALNUT DR
BUFFALO OK
73834
US

V. Phone/Fax

Practice location:
  • Phone: 580-735-2415
  • Fax: 580-735-2165
Mailing address:
  • Phone: 580-735-2415
  • Fax: 580-735-2165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH3001-3001
License Number StateOK

VIII. Authorized Official

Name: MIKE DIMOND
Title or Position: MANAGER
Credential:
Phone: 405-943-1144