Provider Demographics
NPI:1568567113
Name:CLINTON NURSING CENTER, LLC
Entity Type:Organization
Organization Name:CLINTON NURSING CENTER, LLC
Other - Org Name:GRACE LIVING CENTER - CLINTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-943-1144
Mailing Address - Street 1:2400 W MODELLE AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-3724
Mailing Address - Country:US
Mailing Address - Phone:580-323-1110
Mailing Address - Fax:580-323-3858
Practice Address - Street 1:2400 W MODELLE AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-3724
Practice Address - Country:US
Practice Address - Phone:580-323-1110
Practice Address - Fax:580-323-3858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH2001-2001314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100810380CMedicaid
OK375141Medicare ID - Type Unspecified