Provider Demographics
NPI:1891784070
Name:OAK GROVE MANOR, INC
Entity Type:Organization
Organization Name:OAK GROVE MANOR, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEWEY
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:PEBWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-286-2537
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-0299
Mailing Address - Country:US
Mailing Address - Phone:580-286-2537
Mailing Address - Fax:580-286-5480
Practice Address - Street 1:HIGHWAY 259 SOUTH
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745
Practice Address - Country:US
Practice Address - Phone:580-286-2537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH4505-4505313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375201Medicare Oscar/Certification