Provider Demographics
NPI:1801913371
Name:BROKEN ARROW NURSING HOME INC
Entity type:Organization
Organization Name:BROKEN ARROW NURSING HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-251-5343
Mailing Address - Street 1:424 N DATE AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-3872
Mailing Address - Country:US
Mailing Address - Phone:918-251-5343
Mailing Address - Fax:918-258-9942
Practice Address - Street 1:424 N DATE AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-3872
Practice Address - Country:US
Practice Address - Phone:918-251-5343
Practice Address - Fax:918-258-9942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7205313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100772960AMedicaid
OK100772960AMedicaid