Provider Demographics
NPI:1013016864
Name:GRAND UNION HEALTHCARE L.L.C,
Entity Type:Organization
Organization Name:GRAND UNION HEALTHCARE L.L.C,
Other - Org Name:MONROE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ORRISE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-253-4500
Mailing Address - Street 1:PO BOX 409
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:OK
Mailing Address - Zip Code:74346-0409
Mailing Address - Country:US
Mailing Address - Phone:918-253-4500
Mailing Address - Fax:918-253-6064
Practice Address - Street 1:226 EAST MONROE STREET
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:OK
Practice Address - Zip Code:74346-0409
Practice Address - Country:US
Practice Address - Phone:918-253-4500
Practice Address - Fax:918-253-6064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100778240AMedicaid
OK100778240AMedicaid