Provider Demographics
NPI:1639156888
Name:GRAND UNION HEALTHCARE
Entity Type:Organization
Organization Name:GRAND UNION HEALTHCARE
Other - Org Name:MONROE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ORRISE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-253-4500
Mailing Address - Street 1:PO BOX 409
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:OK
Mailing Address - Zip Code:74346-0409
Mailing Address - Country:US
Mailing Address - Phone:918-253-4500
Mailing Address - Fax:918-253-6064
Practice Address - Street 1:226 E MONROE
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:OK
Practice Address - Zip Code:74346
Practice Address - Country:US
Practice Address - Phone:918-253-4500
Practice Address - Fax:918-253-6064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH2104-2104313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
375415Medicare ID - Type Unspecified