Healthcare Provider Details

I. General information

NPI: 1891795100
Provider Name (Legal Business Name): HASKELL CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 N CHOCTAW AVENUE
HASKELL OK
74436-1319
US

IV. Provider business mailing address

405 N CHOCTAW AVENUE
HASKELL OK
74436-1319
US

V. Phone/Fax

Practice location:
  • Phone: 918-482-3310
  • Fax: 918-482-6801
Mailing address:
  • Phone: 918-482-3310
  • Fax: 918-482-6901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH5104-5104
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100772190A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name: PAM HUMPHREYS
Title or Position: OWNER
Credential:
Phone: 405-379-0039