Provider Demographics
NPI:1003027921
Name:PERRY GREEN VALLEY NURSING HOME LLC
Entity Type:Organization
Organization Name:PERRY GREEN VALLEY NURSING HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TANDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HASTINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-282-6285
Mailing Address - Street 1:PO BOX 1095
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-1095
Mailing Address - Country:US
Mailing Address - Phone:405-282-6285
Mailing Address - Fax:405-282-5731
Practice Address - Street 1:1103 BIRCH ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OK
Practice Address - Zip Code:73077-6269
Practice Address - Country:US
Practice Address - Phone:580-336-2285
Practice Address - Fax:580-336-3445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5202314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200114510AMedicaid
375373Medicare Oscar/Certification