Healthcare Provider Details

I. General information

NPI: 1114220191
Provider Name (Legal Business Name): SUMMIT HEALTHCARE RECEIVERSHIP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 08/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 N. 6TH
OKEENE OK
73763
US

IV. Provider business mailing address

PO BOX 1218
NICOMA PARK OK
73066-1218
US

V. Phone/Fax

Practice location:
  • Phone: 580-822-4441
  • Fax: 580-822-4431
Mailing address:
  • Phone: 405-769-7990
  • Fax: 405-769-7970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH0601
License Number StateOK

VIII. Authorized Official

Name: RANDY GOODMAN
Title or Position: RECEIVER
Credential:
Phone: 405-769-7990