Healthcare Provider Details

I. General information

NPI: 1467852244
Provider Name (Legal Business Name): JLG HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 W ELK
DUNCAN OK
73533-1196
US

IV. Provider business mailing address

1603 TIMBERCREEK DR
DUNCAN OK
73533-1196
US

V. Phone/Fax

Practice location:
  • Phone: 580-658-2319
  • Fax:
Mailing address:
  • Phone: 580-658-2319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH6902-6902
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH6902-6902
License Number StateOK

VIII. Authorized Official

Name: JEFF L GREGSTON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 580-658-2319