Healthcare Provider Details

I. General information

NPI: 1083663512
Provider Name (Legal Business Name): EASTGATE VILLAGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 HASKELL BLVD
MUSKOGEE OK
74403-3915
US

IV. Provider business mailing address

3500 HASKELL BLVD
MUSKOGEE OK
74403-3915
US

V. Phone/Fax

Practice location:
  • Phone: 918-682-3191
  • Fax: 918-682-1131
Mailing address:
  • Phone: 918-682-3191
  • Fax: 918-682-1131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH5113-5113
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH5113-5113
License Number StateOK

VIII. Authorized Official

Name: MRS. MARY LOUISE FLETCHER
Title or Position: ADMINISTRATOR
Credential:
Phone: 918-682-3191