Provider Demographics
NPI:1437159761
Name:OKEMAH CARE CENTER, LLC
Entity Type:Organization
Organization Name:OKEMAH CARE CENTER, LLC
Other - Org Name:OKEMAH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-379-0039
Mailing Address - Street 1:112 N WOODY GUTHRIE ST
Mailing Address - Street 2:
Mailing Address - City:OKEMAH
Mailing Address - State:OK
Mailing Address - Zip Code:74859-2642
Mailing Address - Country:US
Mailing Address - Phone:918-623-1126
Mailing Address - Fax:918-623-1765
Practice Address - Street 1:112 N WOODY GUTHRIE ST
Practice Address - Street 2:
Practice Address - City:OKEMAH
Practice Address - State:OK
Practice Address - Zip Code:74859-2642
Practice Address - Country:US
Practice Address - Phone:918-623-1126
Practice Address - Fax:918-623-1765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5404-5404313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375420Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER