Healthcare Provider Details

I. General information

NPI: 1720161813
Provider Name (Legal Business Name): BRENTWOOD EXTENDED CARE & REHAB. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 N 38TH ST
MUSKOGEE OK
74401-2056
US

IV. Provider business mailing address

1929 BETTY JANE LN
MUSKOGEE OK
74403-1581
US

V. Phone/Fax

Practice location:
  • Phone: 918-683-8070
  • Fax: 918-683-8234
Mailing address:
  • Phone: 918-683-9407
  • Fax: 918-683-1979

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: MRS. BOBBIE MONTGOMERY
Title or Position: OWNER
Credential:
Phone: 918-683-9407