Provider Demographics
NPI:1013914779
Name:WALNUT GROVE LIVING CENTER, INC.
Entity Type:Organization
Organization Name:WALNUT GROVE LIVING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-423-7373
Mailing Address - Street 1:PO BOX 3303
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74502-3303
Mailing Address - Country:US
Mailing Address - Phone:918-423-7373
Mailing Address - Fax:918-423-7156
Practice Address - Street 1:1001 S GEORGE NIGH EXPY
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-7286
Practice Address - Country:US
Practice Address - Phone:918-423-7373
Practice Address - Fax:918-423-7156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH6110-6110313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100776710AMedicaid
OK100776710AMedicaid