Healthcare Provider Details

I. General information

NPI: 1154310399
Provider Name (Legal Business Name): POTEAU NURSING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 CLAYTON AVE
POTEAU OK
74953-4102
US

IV. Provider business mailing address

1805 E 15TH ST
TULSA OK
74104-4610
US

V. Phone/Fax

Practice location:
  • Phone: 918-647-8236
  • Fax: 918-649-3747
Mailing address:
  • Phone: 918-622-4799
  • Fax: 918-622-4798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH40094009
License Number StateOK

VIII. Authorized Official

Name: MARK LIETZKE
Title or Position: CEO
Credential:
Phone: 918-622-4799