Provider Demographics
NPI:1508103763
Name:NW 61ST NURSING, LLC
Entity Type:Organization
Organization Name:NW 61ST NURSING, LLC
Other - Org Name:NORTHWEST NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:BOYD
Authorized Official - Middle Name:P
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-869-5116
Mailing Address - Street 1:2801 NW 61ST ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-7007
Mailing Address - Country:US
Mailing Address - Phone:405-842-6601
Mailing Address - Fax:405-810-8482
Practice Address - Street 1:2801 NW 61ST ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-7007
Practice Address - Country:US
Practice Address - Phone:405-842-6601
Practice Address - Fax:405-810-8482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-08
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5524-5524314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
375520Medicare Oscar/Certification