Provider Demographics
NPI:1437146529
Name:SHADY REST CARE CENTER, LLC
Entity Type:Organization
Organization Name:SHADY REST CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP IN CHARGE OF REIMBURSEMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-775-6200
Mailing Address - Street 1:1505 W CHICKASAW AVE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-7201
Mailing Address - Country:US
Mailing Address - Phone:918-775-6200
Mailing Address - Fax:918-775-5643
Practice Address - Street 1:210 S ADAIR ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-5202
Practice Address - Country:US
Practice Address - Phone:918-825-4455
Practice Address - Fax:918-825-8493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK314000000X314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100777350AMedicaid
OK100777350AMedicaid