Provider Demographics
NPI:1689664716
Name:TOWN OF VICI
Entity Type:Organization
Organization Name:TOWN OF VICI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:BS BUSINESS ADMIN
Authorized Official - Phone:580-995-4216
Mailing Address - Street 1:619 SPECK
Mailing Address - Street 2:PO BOX 119
Mailing Address - City:VICI
Mailing Address - State:OK
Mailing Address - Zip Code:73859-0119
Mailing Address - Country:US
Mailing Address - Phone:580-995-4216
Mailing Address - Fax:580-995-4237
Practice Address - Street 1:619 SPECK
Practice Address - Street 2:
Practice Address - City:VICI
Practice Address - State:OK
Practice Address - Zip Code:73859-0119
Practice Address - Country:US
Practice Address - Phone:580-995-4216
Practice Address - Fax:580-995-4237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH2202-2202314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK10077838AMedicaid