MEDICARE: CORN HERITAGE VILAGE OF WEATHERFORD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	NH2002-2002	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023241494
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORN HERITAGE VILAGE OF WEATHERFORD

Provider Business Mailing Address
First Line	:	801 N WASHINGTON ST
Second Line	:
City	:	WEATHERFORD
State	:	OK
Zip	:	73096-4032
Country	:	US
Telephone Number	:	580-772-3993
Fax Number	:	580-772-1032

Provider Business Practice Location Address
First Line	:	801 N WASHINGTON ST
Second Line	:
City	:	WEATHERFORD
State	:	OK
Zip	:	73096-4032
Country	:	US
Telephone Number	:	580-772-3993
Fax Number	:	580-772-1032

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MARTIN HALL
Credential	:
Telephone Number	:	580-772-3993

Provider Enumeration Date	:	09/01/2009
Last Update Date	:	09/01/2009

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