MEDICARE: CLINTON NURSING CENTER, LLC

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	NH2001-2001	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	:	1568567113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINTON NURSING CENTER, LLC

Provider Business Mailing Address
First Line	:	2400 W MODELLE AVE
Second Line	:
City	:	CLINTON
State	:	OK
Zip	:	73601-3724
Country	:	US
Telephone Number	:	580-323-1110
Fax Number	:	580-323-3858

Provider Business Practice Location Address
First Line	:	2400 W MODELLE AVE
Second Line	:
City	:	CLINTON
State	:	OK
Zip	:	73601-3724
Country	:	US
Telephone Number	:	580-323-1110
Fax Number	:	580-323-3858

Authorized Official
Title or Position	:	DIRECTOR OF REIMBURSEMENT
Name	:	KRISTY DEROIN
Credential	:
Telephone Number	:	405-943-1144

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	02/05/2026

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