Provider Demographics
NPI:1003659855
Name:NOWATA LTC LLC
Entity type:Organization
Organization Name:NOWATA LTC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:LANCE
Authorized Official - Last Name:GUYMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-312-8050
Mailing Address - Street 1:210 E CHOCTAW AVE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-4604
Mailing Address - Country:US
Mailing Address - Phone:918-775-4439
Mailing Address - Fax:
Practice Address - Street 1:436 S JOE ST
Practice Address - Street 2:
Practice Address - City:NOWATA
Practice Address - State:OK
Practice Address - Zip Code:74048-3233
Practice Address - Country:US
Practice Address - Phone:918-775-4439
Practice Address - Fax:918-775-9242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility