Healthcare Provider Details

I. General information

NPI: 1396973210
Provider Name (Legal Business Name): CORN HERITAGE VILLAGE OF CORN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 W ADAMS STREET
CORN OK
73024
US

IV. Provider business mailing address

PO BOX 98
CORN OK
73024-0098
US

V. Phone/Fax

Practice location:
  • Phone: 580-343-2295
  • Fax: 580-343-2297
Mailing address:
  • Phone: 580-343-2295
  • Fax: 580-343-2297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH7502-7502
License Number StateOK

VIII. Authorized Official

Name: MR. MARTIN HALL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 580-343-2295