=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144326489
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REBOLD MANOR L L C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 10/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 E 6TH ST
-----------------------------------------------------
City | OKMULGEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74447-4807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-756-1967
-----------------------------------------------------
Fax | 918-756-4271
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1701 E 6TH ST
-----------------------------------------------------
City | OKMULGEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74447-4807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-756-1967
-----------------------------------------------------
Fax | 918-756-4271
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF REIMBURSEMENT
-----------------------------------------------------
Name | KRISTY DEROIN
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 405-943-1144
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | NH5608-5608
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------