Healthcare Provider Details

I. General information

NPI: 1619964681
Provider Name (Legal Business Name): LOCUST GROVE CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 WYANDOTTE & ROSS
LOCUST GROVE OK
74352
US

IV. Provider business mailing address

201 N ELM ST SUITE A
SALLISAW OK
74955-4633
US

V. Phone/Fax

Practice location:
  • Phone: 918-479-5784
  • Fax: 918-479-6254
Mailing address:
  • Phone: 918-775-6200
  • Fax: 918-775-5643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. SANDRA TAYLOR
Title or Position: VP IN CHARGE OF REIMBURSEMENT
Credential:
Phone: 918-775-6200