Healthcare Provider Details

I. General information

NPI: 1851472922
Provider Name (Legal Business Name): MEDICALODGES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 BARTLES ROAD
DEWEY OK
74029-0520
US

IV. Provider business mailing address

430 BARTLES ROAD P.O. BOX 520
DEWEY OK
74029-0520
US

V. Phone/Fax

Practice location:
  • Phone: 918-534-2848
  • Fax: 918-534-2558
Mailing address:
  • Phone: 918-534-2848
  • Fax: 918-534-2558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH74047404
License Number StateOK

VIII. Authorized Official

Name: MR. SCOTT L HINES
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 620-709-0305