Provider Demographics
NPI:1639178130
Name:COAL COUNTY EXTENDED CARE INCORPORATED
Entity Type:Organization
Organization Name:COAL COUNTY EXTENDED CARE INCORPORATED
Other - Org Name:RUTH WILSON HURLEY MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOURLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-927-2327
Mailing Address - Street 1:7 N COVINGTON ST
Mailing Address - Street 2:
Mailing Address - City:COALGATE
Mailing Address - State:OK
Mailing Address - Zip Code:74538-2001
Mailing Address - Country:US
Mailing Address - Phone:580-927-2377
Mailing Address - Fax:580-927-9940
Practice Address - Street 1:7 N COVINGTON ST
Practice Address - Street 2:
Practice Address - City:COALGATE
Practice Address - State:OK
Practice Address - Zip Code:74538-2001
Practice Address - Country:US
Practice Address - Phone:580-927-2000
Practice Address - Fax:580-927-9940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH1501-1501313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100774650AMedicaid
OK375312Medicare Oscar/Certification