Provider Demographics
NPI:1740313048
Name:GLENHAVEN CORPORATION
Entity type:Organization
Organization Name:GLENHAVEN CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-224-0909
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:3003 IOWA
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73023-0400
Mailing Address - Country:US
Mailing Address - Phone:405-224-0909
Mailing Address - Fax:405-224-6975
Practice Address - Street 1:3003 W IOWA AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-6026
Practice Address - Country:US
Practice Address - Phone:405-224-0909
Practice Address - Fax:405-224-6975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKCC2601-2601310400000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200061060AMedicaid
5579110001Medicare NSC
OK37-5359Medicare ID - Type Unspecified
OK200061060AMedicaid