Healthcare Provider Details

I. General information

NPI: 1023113826
Provider Name (Legal Business Name): STILLWATER NURSING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 W 10TH AVE
STILLWATER OK
74074-5420
US

IV. Provider business mailing address

1215 W 10TH AVE
STILLWATER OK
74074-5420
US

V. Phone/Fax

Practice location:
  • Phone: 405-372-1000
  • Fax: 405-377-7051
Mailing address:
  • Phone: 405-372-1000
  • Fax: 405-377-7051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH6004-6004
License Number StateOK

VIII. Authorized Official

Name: MIKE DIMOND
Title or Position: MANAGER
Credential:
Phone: 405-943-1144