Provider Demographics
NPI:1740404409
Name:MIKE BUSSEY, RECEIVER, LLC
Entity Type:Organization
Organization Name:MIKE BUSSEY, RECEIVER, LLC
Other - Org Name:SUNSET ESTATES OF EL RENO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:S.
Authorized Official - Middle Name:WENDY
Authorized Official - Last Name:MCENTIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-737-0881
Mailing Address - Street 1:1380 S. DOUGLAS BLVD.
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-5215
Mailing Address - Country:US
Mailing Address - Phone:405-737-0881
Mailing Address - Fax:405-737-0899
Practice Address - Street 1:2100 TOWNSEND DR
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-2116
Practice Address - Country:US
Practice Address - Phone:405-262-3323
Practice Address - Fax:405-262-3328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK06049313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20008750AMedicaid
OK375448Medicare ID - Type Unspecified