Provider Demographics
NPI:1588663520
Name:ARTESIAN HOME, INC.
Entity Type:Organization
Organization Name:ARTESIAN HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:C
Authorized Official - Last Name:COBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-226-3055
Mailing Address - Street 1:1415 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:OK
Mailing Address - Zip Code:73086-2003
Mailing Address - Country:US
Mailing Address - Phone:580-622-2030
Mailing Address - Fax:580-622-5752
Practice Address - Street 1:1415 W 15TH ST
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:OK
Practice Address - Zip Code:73086-2003
Practice Address - Country:US
Practice Address - Phone:580-622-2030
Practice Address - Fax:580-622-5752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2023-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5001-5001313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100770850 AMedicaid
OK375289Medicare ID - Type UnspecifiedPROVIDER NUMBER