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General NPI Number Information
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NPI Number | 1083663512
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Entity Type | Organization
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Legal Business Name | EASTGATE VILLAGE LLC
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Dates
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Enumeration Date | 05/10/2006
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 3500 HASKELL BLVD
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City | MUSKOGEE
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State | OK
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Zip | 74403-3915
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Country | US
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Telephone | 918-682-3191
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Fax | 918-682-1131
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Provider Business Mailing Address
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Address Line | 3500 HASKELL BLVD
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City | MUSKOGEE
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State | OK
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Zip | 74403-3915
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Country | US
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Telephone | 918-682-3191
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Fax | 918-682-1131
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. MARY LOUISE FLETCHER
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Credential |
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Telephone | 918-682-3191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | NH5113-5113
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | NH5113-5113
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License Number State | OK
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