Provider Demographics
NPI:1457351827
Name:GGP, LLC
Entity Type:Organization
Organization Name:GGP, LLC
Other - Org Name:GRAN GRAN'S PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NELL
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-350-2311
Mailing Address - Street 1:1110 S CORNWELL DR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-4632
Mailing Address - Country:US
Mailing Address - Phone:405-350-2311
Mailing Address - Fax:405-350-2379
Practice Address - Street 1:1110 S CORNWELL DR
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-4632
Practice Address - Country:US
Practice Address - Phone:405-350-2311
Practice Address - Fax:405-350-2379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH0905-0905313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100778340AMedicaid