Provider Demographics
NPI:1225094766
Name:WAGONER CARE CENTER LLC
Entity Type:Organization
Organization Name:WAGONER CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MDS/CPC
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:JR
Authorized Official - Credentials:LPN
Authorized Official - Phone:918-485-2203
Mailing Address - Street 1:205 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-3915
Mailing Address - Country:US
Mailing Address - Phone:918-485-2203
Mailing Address - Fax:918-485-6673
Practice Address - Street 1:205 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-3915
Practice Address - Country:US
Practice Address - Phone:918-485-2203
Practice Address - Fax:918-485-6673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH7302-7302313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375369Medicare ID - Type Unspecified