Healthcare Provider Details

I. General information

NPI: 1144326489
Provider Name (Legal Business Name): REBOLD MANOR L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E 6TH ST
OKMULGEE OK
74447-4807
US

IV. Provider business mailing address

1701 E 6TH ST
OKMULGEE OK
74447-4807
US

V. Phone/Fax

Practice location:
  • Phone: 918-756-1967
  • Fax: 918-756-4271
Mailing address:
  • Phone: 918-756-1967
  • Fax: 918-756-4271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH5608-5608
License Number StateOK

VIII. Authorized Official

Name: KRISTY DEROIN
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential: MBA
Phone: 405-943-1144