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General NPI Number Information
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NPI Number | 1891784070
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Entity Type | Organization
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Legal Business Name | OAK GROVE MANOR, INC
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Dates
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Enumeration Date | 10/19/2005
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Last Update Date | 02/25/2008
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Provider Practice Location Address
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Address Line | HIGHWAY 259 SOUTH
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City | IDABEL
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State | OK
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Zip | 74745
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Country | US
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Telephone | 580-286-2537
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 299
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City | IDABEL
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State | OK
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Zip | 74745-0299
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Country | US
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Telephone | 580-286-2537
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Fax | 580-286-5480
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. DEWEY DEWAYNE PEBWORTH
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Credential |
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Telephone | 580-286-2537
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | NH4505-4505
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | NH4505-4505
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License Number State | OK
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