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General NPI Number Information
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NPI Number | 1639178130
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Entity Type | Organization
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Legal Business Name | COAL COUNTY EXTENDED CARE INCORPORATED
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Dates
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Enumeration Date | 07/18/2005
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Last Update Date | 07/07/2020
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Provider Practice Location Address
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Address Line | 7 N COVINGTON ST
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City | COALGATE
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State | OK
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Zip | 74538-2001
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Country | US
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Telephone | 580-927-2000
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Fax | 580-927-9940
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Provider Business Mailing Address
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Address Line | 7 N COVINGTON ST
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City | COALGATE
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State | OK
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Zip | 74538-2001
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Country | US
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Telephone | 580-927-2377
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Fax | 580-927-9940
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MR. TRENT A. BOURLAND
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Credential |
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Telephone | 580-927-2327
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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 | NH1501-1501
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | NH1501-1501
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License Number State | OK
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