Provider Demographics
NPI:1568141208
Name:LATIMER LONG TERM CARE LLC
Entity Type:Organization
Organization Name:LATIMER LONG TERM CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:918-465-9300
Mailing Address - Street 1:225 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-4045
Mailing Address - Country:US
Mailing Address - Phone:918-465-9300
Mailing Address - Fax:
Practice Address - Street 1:103 SW 9TH ST
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-3604
Practice Address - Country:US
Practice Address - Phone:918-465-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility