Provider Demographics
NPI:1396973210
Name:CORN HERITAGE VILLAGE OF CORN INC
Entity type:Organization
Organization Name:CORN HERITAGE VILLAGE OF CORN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-343-2295
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:CORN
Mailing Address - State:OK
Mailing Address - Zip Code:73024-0098
Mailing Address - Country:US
Mailing Address - Phone:580-343-2295
Mailing Address - Fax:580-343-2297
Practice Address - Street 1:106 W ADAMS STREET
Practice Address - Street 2:
Practice Address - City:CORN
Practice Address - State:OK
Practice Address - Zip Code:73024
Practice Address - Country:US
Practice Address - Phone:580-343-2295
Practice Address - Fax:580-343-2297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH7502-7502313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200265350AMedicaid
OK375409Medicare Oscar/Certification