Provider Demographics
NPI:1922101088
Name:MEDI-HOME OF ARKOMA INC
Entity Type:Organization
Organization Name:MEDI-HOME OF ARKOMA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-875-3107
Mailing Address - Street 1:PO BOX 410
Mailing Address - Street 2:
Mailing Address - City:ARKOMA
Mailing Address - State:OK
Mailing Address - Zip Code:74901-0410
Mailing Address - Country:US
Mailing Address - Phone:918-875-3107
Mailing Address - Fax:918-875-3021
Practice Address - Street 1:1008 ARKANSAS STREET
Practice Address - Street 2:
Practice Address - City:ARKOMA
Practice Address - State:OK
Practice Address - Zip Code:74901-0410
Practice Address - Country:US
Practice Address - Phone:918-875-3107
Practice Address - Fax:918-875-3021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH4003-4003314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375371Medicare Oscar/Certification