MEDICARE: COUNTRY STYLE HEALTH CARE, INC. XI

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	251E00000X	Home Health Agency	HC7956	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HC7956	OTHER	OK	STATE LICENSE

General Provider Information

NPI Number	:	1255641155
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRY STYLE HEALTH CARE, INC. XI

Provider Business Mailing Address
First Line	:	9160 NW HIGHWAY 2
Second Line	:
City	:	WILBURTON
State	:	OK
Zip	:	74578-5306
Country	:	US
Telephone Number	:	918-465-2626
Fax Number	:	918-465-0042

Provider Business Practice Location Address
First Line	:	2313 NORTH MAIN ST
Second Line	:
City	:	GORE
State	:	OK
Zip	:	74435-2024
Country	:	US
Telephone Number	:	918-489-5519
Fax Number	:	918-489-5530

Authorized Official
Title or Position	:	VP OF OPERATIONS
Name	:	MRS. JACKIE BROWNE
Credential	:
Telephone Number	:	918-465-2626

Provider Enumeration Date	:	10/14/2010
Last Update Date	:	12/27/2016

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