MEDICARE: WASHITA VALLEY 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	NH25012501	OK

General Provider Information

NPI Number	:	1528075546
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASHITA VALLEY LIVING CENTER, INC

Provider Business Mailing Address
First Line	:	105 WASHINGTON ST
Second Line	:
City	:	PAULS VALLEY
State	:	OK
Zip	:	73075-5039
Country	:	US
Telephone Number	:	405-238-5528
Fax Number	:	405-238-7989

Provider Business Practice Location Address
First Line	:	105 WASHINGTON ST
Second Line	:
City	:	PAULS VALLEY
State	:	OK
Zip	:	73075-5039
Country	:	US
Telephone Number	:	405-238-5528
Fax Number	:	405-238-7989

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JACK JUSTICE
Credential	:
Telephone Number	:	405-238-5528

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	07/16/2007

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