Provider Demographics
NPI:1578550331
Name:SEMINOLE NURSING HOME INC
Entity Type:Organization
Organization Name:SEMINOLE NURSING HOME INC
Other - Org Name:SEMINOLE PIONEER NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE/MEDICARE
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:PITA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-622-6300
Mailing Address - Street 1:1705 BOREN BLVD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74868-2725
Mailing Address - Country:US
Mailing Address - Phone:405-382-1270
Mailing Address - Fax:405-382-3199
Practice Address - Street 1:1705 BOREN BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-2725
Practice Address - Country:US
Practice Address - Phone:405-382-1270
Practice Address - Fax:405-382-3199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH6704-6704313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200004720AMedicaid
OK000375350001OtherBLUE CROSS BLUE SHIELD OK
OK37-5350Medicare ID - Type UnspecifiedMEDICARE OKLAHOMA