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General NPI Number Information
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NPI Number | 1154310399
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Entity Type | Organization
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Legal Business Name | POTEAU NURSING CENTER, LLC
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Dates
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Enumeration Date | 10/20/2005
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Last Update Date | 08/26/2021
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Provider Practice Location Address
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Address Line | 1501 CLAYTON AVE
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City | POTEAU
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State | OK
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Zip | 74953-4102
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Country | US
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Telephone | 918-647-8236
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Fax | 918-649-3747
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Provider Business Mailing Address
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Address Line | 1805 E 15TH ST
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City | TULSA
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State | OK
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Zip | 74104-4610
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Country | US
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Telephone | 918-622-4799
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Fax | 918-622-4798
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Authorized Official
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Title or Position | CEO
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Name | MARK LIETZKE
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Credential |
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Telephone | 918-622-4799
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | NH40094009
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License Number State | OK
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