Healthcare Provider Details

I. General information

NPI: 1215142591
Provider Name (Legal Business Name): MILLERCOZYHOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 N GUNTER ST
VINITA OK
74301-2903
US

IV. Provider business mailing address

PO BOX 459
VINITA OK
74301-0459
US

V. Phone/Fax

Practice location:
  • Phone: 918-256-3796
  • Fax: 918-256-3692
Mailing address:
  • Phone: 918-256-3796
  • Fax: 918-256-3692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberRC1803-1803
License Number StateOK

VIII. Authorized Official

Name: MRS. SHIRLEY BREWER
Title or Position: ASST. ADMINISTRATOR
Credential:
Phone: 918-256-7291