Provider Demographics
NPI:1740412998
Name:PAULS VALLEY CARE CENTER LLC
Entity Type:Organization
Organization Name:PAULS VALLEY CARE CENTER LLC
Other - Org Name:PAULS VALLEY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BART
Authorized Official - Middle Name:
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-436-0950
Mailing Address - Street 1:1413 S CHICKASAW ST
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-6415
Mailing Address - Country:US
Mailing Address - Phone:405-238-6411
Mailing Address - Fax:
Practice Address - Street 1:1413 S CHICKASAW ST
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-6415
Practice Address - Country:US
Practice Address - Phone:405-238-6411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH2504-2504313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100778860AMedicaid
375463Medicare Oscar/Certification