Provider Demographics
NPI:1790747798
Name:WALNUT GROVE LIVING CENTER
Entity Type:Organization
Organization Name:WALNUT GROVE LIVING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:WAYNETTA
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-423-7373
Mailing Address - Street 1:PO BOX 3303
Mailing Address - Street 2:1001 S GEORGE NIGH EXPWY
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74502
Mailing Address - Country:US
Mailing Address - Phone:918-423-7373
Mailing Address - Fax:918-423-7156
Practice Address - Street 1:1001 S GEORGE NIGH EXPWY
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74502
Practice Address - Country:US
Practice Address - Phone:918-423-7373
Practice Address - Fax:918-423-7156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
375340Medicare ID - Type Unspecified