Provider Demographics
NPI:1437254158
Name:MANGUM NURSING CENTER, LLC
Entity Type:Organization
Organization Name:MANGUM NURSING CENTER, LLC
Other - Org Name:GRACE LIVING CENTER - MANGUM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-943-1144
Mailing Address - Street 1:320 CAREY AVE
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554-1624
Mailing Address - Country:US
Mailing Address - Phone:580-782-3346
Mailing Address - Fax:580-782-3126
Practice Address - Street 1:320 CAREY AVE
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-1624
Practice Address - Country:US
Practice Address - Phone:580-782-3346
Practice Address - Fax:580-782-3126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH2801-2801314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100776780AMedicaid
OK100776780AMedicaid