Provider Demographics
NPI:1508658816
Name:STATE OF OKLAHOMA HUMAN SERVICES
Entity type:Organization
Organization Name:STATE OF OKLAHOMA HUMAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED NURSING HOME ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:EWING
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:580-805-1400
Mailing Address - Street 1:2616 NORTH 30TH STREET
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-8760
Mailing Address - Country:US
Mailing Address - Phone:580-213-2700
Mailing Address - Fax:580-358-8013
Practice Address - Street 1:2616 NORTH 30TH STREET
Practice Address - Street 2:SUITE F BUILDING 5
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-8760
Practice Address - Country:US
Practice Address - Phone:580-213-2700
Practice Address - Fax:580-358-8013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100769310-AMedicaid