Healthcare Provider Details

I. General information

NPI: 1144225251
Provider Name (Legal Business Name): PSG-TUTTLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 SE 4TH ST
TUTTLE OK
73089-8825
US

IV. Provider business mailing address

104 SE 4TH ST
TUTTLE OK
73089-8825
US

V. Phone/Fax

Practice location:
  • Phone: 405-381-3363
  • Fax: 405-381-0827
Mailing address:
  • Phone: 405-381-3363
  • Fax: 405-381-0827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH2601
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. ROSANN YEAKLEY
Title or Position: ADMINSTRATOR
Credential:
Phone: 405-381-3363