Provider Demographics
NPI:1023142981
Name:FORT GIBSON MANAGEMENT LLC
Entity type:Organization
Organization Name:FORT GIBSON MANAGEMENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-478-2456
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434-0190
Mailing Address - Country:US
Mailing Address - Phone:918-478-2456
Mailing Address - Fax:918-478-3250
Practice Address - Street 1:205 E POPLAR
Practice Address - Street 2:
Practice Address - City:FORT GIBSON
Practice Address - State:OK
Practice Address - Zip Code:74431
Practice Address - Country:US
Practice Address - Phone:918-478-2456
Practice Address - Fax:918-478-3258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5103-5103314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375330Medicare ID - Type Unspecified