MEDICARE: QUAIL RIDGE LIVING CENTER INC

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	314000000X	Skilled Nursing Facility	NH21052105	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000375175001	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1396841094
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUAIL RIDGE LIVING CENTER INC

Provider Business Mailing Address
First Line	:	PO BOX 1005
Second Line	:
City	:	SILOAM SPRINGS
State	:	AR
Zip	:	72761
Country	:	US
Telephone Number	:	918-422-5139
Fax Number	:	918-422-9998

Provider Business Practice Location Address
First Line	:	564 STATE LINE RD
Second Line	:
City	:	COLCORD
State	:	OK
Zip	:	74338
Country	:	US
Telephone Number	:	918-422-5139
Fax Number	:	918-422-9998

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. LINDA LEA CARTER
Credential	:
Telephone Number	:	918-422-5139

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	08/22/2020

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