Provider Demographics
NPI:1326059676
Name:CORDELL CHRISTIAN HOME INCORPORATED
Entity Type:Organization
Organization Name:CORDELL CHRISTIAN HOME INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-832-3371
Mailing Address - Street 1:1400 N COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:CORDELL
Mailing Address - State:OK
Mailing Address - Zip Code:73632-1822
Mailing Address - Country:US
Mailing Address - Phone:580-832-3371
Mailing Address - Fax:580-832-2732
Practice Address - Street 1:1400 N COLLEGE ST
Practice Address - Street 2:
Practice Address - City:CORDELL
Practice Address - State:OK
Practice Address - Zip Code:73632-1822
Practice Address - Country:US
Practice Address - Phone:580-832-3371
Practice Address - Fax:580-832-2732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH7501-7501314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100773140 AMedicaid
OK100773140 AMedicaid