=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164493904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CIMARRON MEMORIAL HOSPITAL AND NURSING HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2006
-----------------------------------------------------
Last Update Date | 10/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 S ELLIS
-----------------------------------------------------
City | BOISE CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73933-1059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-544-2501
-----------------------------------------------------
Fax | 580-544-2517
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1059
-----------------------------------------------------
City | BOISE CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73933-1059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-544-2501
-----------------------------------------------------
Fax | 580-544-2517
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JONATHAN GLEASON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 580-589-0231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------