Healthcare Provider Details

I. General information

NPI: 1013016864
Provider Name (Legal Business Name): GRAND UNION HEALTHCARE L.L.C,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 EAST MONROE STREET
JAY OK
74346-0409
US

IV. Provider business mailing address

PO BOX 409
JAY OK
74346-0409
US

V. Phone/Fax

Practice location:
  • Phone: 918-253-4500
  • Fax: 918-253-6064
Mailing address:
  • Phone: 918-253-4500
  • Fax: 918-253-6064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: ORRISE MATHESON
Title or Position: ADMINISTRATOR
Credential:
Phone: 918-253-4500