Provider Demographics
NPI:1891795100
Name:HASKELL CARE CENTER LLC
Entity Type:Organization
Organization Name:HASKELL CARE CENTER LLC
Other - Org Name:HASKELL CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-379-0039
Mailing Address - Street 1:405 N CHOCTAW AVENUE
Mailing Address - Street 2:
Mailing Address - City:HASKELL
Mailing Address - State:OK
Mailing Address - Zip Code:74436-1319
Mailing Address - Country:US
Mailing Address - Phone:918-482-3310
Mailing Address - Fax:918-482-6901
Practice Address - Street 1:405 N CHOCTAW AVENUE
Practice Address - Street 2:
Practice Address - City:HASKELL
Practice Address - State:OK
Practice Address - Zip Code:74436-1319
Practice Address - Country:US
Practice Address - Phone:918-482-3310
Practice Address - Fax:918-482-6801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5104-5104314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100772190AMedicaid
OK100772190AMedicaid