Provider Demographics
NPI:1972509172
Name:WADLEY CARE CENTER
Entity Type:Organization
Organization Name:WADLEY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-527-7798
Mailing Address - Street 1:P.O. BOX 1675
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-1675
Mailing Address - Country:US
Mailing Address - Phone:405-527-7798
Mailing Address - Fax:405-527-5175
Practice Address - Street 1:801 N. 6TH STREET
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080
Practice Address - Country:US
Practice Address - Phone:405-527-7798
Practice Address - Fax:405-527-5175
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WADLEY CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-22
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK375286314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100777470AMedicaid
OK375286Medicare ID - Type Unspecified