Healthcare Provider Details

I. General information

NPI: 1881775070
Provider Name (Legal Business Name): HILLDALE NURSING FACILITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30049 E 151ST STREET SOUTH
COWETA OK
74429
US

IV. Provider business mailing address

PO BOX 490
COWETA OK
74429-0490
US

V. Phone/Fax

Practice location:
  • Phone: 918-486-2166
  • Fax: 918-486-6308
Mailing address:
  • Phone: 918-486-2166
  • Fax: 918-486-6308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH7301-7301
License Number StateOK

VIII. Authorized Official

Name: STACEY SHANKLE
Title or Position: ADMINISTRATOR
Credential:
Phone: 918-486-2166