Provider Demographics
NPI:1619072253
Name:EAST SHAWNEE NURSING CENTER L L C
Entity Type:Organization
Organization Name:EAST SHAWNEE NURSING CENTER L L C
Other - Org Name:GRACE LIVING CENTER - EAST SHAWNEE
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 1:614 E CHERRIE ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3208
Mailing Address - Country:US
Mailing Address - Phone:918-456-2573
Mailing Address - Fax:918-456-6323
Practice Address - Street 1:614 E CHERRIE ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3208
Practice Address - Country:US
Practice Address - Phone:918-456-2573
Practice Address - Fax:918-456-6323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH1103-1103314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100772120AMedicaid