Provider Demographics
NPI:1609394519
Name:CITY OF SAPULPA
Entity Type:Organization
Organization Name:CITY OF SAPULPA
Other - Org Name:BEACON RIDGE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-285-8166
Mailing Address - Street 1:PO BOX 990
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-0990
Mailing Address - Country:US
Mailing Address - Phone:405-285-8166
Mailing Address - Fax:405-563-9447
Practice Address - Street 1:102 E LINE AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-2858
Practice Address - Country:US
Practice Address - Phone:918-216-1811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF SAPULPA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH1902314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKNH1902OtherLICENSE