Provider Demographics
NPI:1801287982
Name:SOUTHERN HILLS REHAB CENTER, LLC
Entity type:Organization
Organization Name:SOUTHERN HILLS REHAB CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-449-2100
Mailing Address - Street 1:5170 S VANDALIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-4079
Mailing Address - Country:US
Mailing Address - Phone:918-496-3963
Mailing Address - Fax:918-496-0774
Practice Address - Street 1:5170 S VANDALIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-4079
Practice Address - Country:US
Practice Address - Phone:918-496-3963
Practice Address - Fax:918-496-0774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200609790BMedicaid
OK200609790AMedicaid