Provider Demographics
NPI:1851520894
Name:ELK CITY NURSING HOME LLC
Entity Type:Organization
Organization Name:ELK CITY NURSING HOME LLC
Other - Org Name:ELK CITY NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:DOUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-333-9545
Mailing Address - Street 1:301 GARRETT ST
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-3113
Mailing Address - Country:US
Mailing Address - Phone:580-225-2811
Mailing Address - Fax:
Practice Address - Street 1:301 GARRETT
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73648-3113
Practice Address - Country:US
Practice Address - Phone:580-225-2811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-13
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH0503-0503314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100771120AMedicaid
OK100771120AMedicaid
375479Medicare PIN