Provider Demographics
NPI:1003815796
Name:N& R OF PONCA CITY LLC
Entity Type:Organization
Organization Name:N& R OF PONCA CITY LLC
Other - Org Name:PONCA CITY NURSING AND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:H
Authorized Official - Last Name:TRUMBO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:502-254-9525
Mailing Address - Street 1:329 TOWNEPARK CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-2348
Mailing Address - Country:US
Mailing Address - Phone:502-254-9525
Mailing Address - Fax:502-254-9919
Practice Address - Street 1:1400 N WAVERLY ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2134
Practice Address - Country:US
Practice Address - Phone:580-762-6668
Practice Address - Fax:580-762-2669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH3606-3606314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100849730AMedicaid
OK375439Medicare Oscar/Certification