Provider Demographics
NPI:1225178429
Name:WAGONER CARE CENTER LLC
Entity Type:Organization
Organization Name:WAGONER CARE CENTER LLC
Other - Org Name:WAGONER CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-967-9285
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:2007-02-07
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK100771420A314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100771420AMedicaid
OK375369Medicare Oscar/Certification