=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487654786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREENBRIER NURSING HOME NUMBER TWO, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2005
-----------------------------------------------------
Last Update Date | 01/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1119 E GARRIOTT RD
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73701-6151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-223-0121
-----------------------------------------------------
Fax | 580-233-3755
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1119 E GARRIOTT RD
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73701-6151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-223-0121
-----------------------------------------------------
Fax | 580-233-3755
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JIM THORPE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 580-233-0121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | NH2404-2404
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------