Healthcare Provider Details

I. General information

NPI: 1619072253
Provider Name (Legal Business Name): EAST SHAWNEE NURSING CENTER L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 E CHERRIE ST
TAHLEQUAH OK
74464-3208
US

IV. Provider business mailing address

614 E CHERRIE ST
TAHLEQUAH OK
74464-3208
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-2573
  • Fax: 918-456-6323
Mailing address:
  • Phone: 918-456-2573
  • Fax: 918-456-6323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH1103-1103
License Number StateOK

VIII. Authorized Official

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