Provider Demographics
NPI:1679698443
Name:GIPSON AND BASE AT WILLOW HAVEN LLC
Entity Type:Organization
Organization Name:GIPSON AND BASE AT WILLOW HAVEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEIVER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-447-3000
Mailing Address - Street 1:114 S PETERS AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6034
Mailing Address - Country:US
Mailing Address - Phone:405-447-3000
Mailing Address - Fax:
Practice Address - Street 1:1301 N 5TH ST
Practice Address - Street 2:
Practice Address - City:TONKAWA
Practice Address - State:OK
Practice Address - Zip Code:74653-1513
Practice Address - Country:US
Practice Address - Phone:580-628-2529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility