Provider Demographics
NPI:1114220191
Name:SUMMIT HEALTHCARE RECEIVERSHIP LLC
Entity Type:Organization
Organization Name:SUMMIT HEALTHCARE RECEIVERSHIP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEIVER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-769-7990
Mailing Address - Street 1:PO BOX 1218
Mailing Address - Street 2:
Mailing Address - City:NICOMA PARK
Mailing Address - State:OK
Mailing Address - Zip Code:73066-1218
Mailing Address - Country:US
Mailing Address - Phone:405-769-7990
Mailing Address - Fax:405-769-7970
Practice Address - Street 1:119 N. 6TH
Practice Address - Street 2:
Practice Address - City:OKEENE
Practice Address - State:OK
Practice Address - Zip Code:73763
Practice Address - Country:US
Practice Address - Phone:580-822-4441
Practice Address - Fax:580-822-4431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH0601314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility