Provider Demographics
NPI:1801991534
Name:PUTNAM CITY CONVALESCENT CENTER, LLC
Entity type:Organization
Organization Name:PUTNAM CITY CONVALESCENT CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-943-1144
Mailing Address - Street 1:7000 NW 32ND ST
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-3910
Mailing Address - Country:US
Mailing Address - Phone:405-789-7242
Mailing Address - Fax:405-495-7562
Practice Address - Street 1:7000 NW 32ND ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-3910
Practice Address - Country:US
Practice Address - Phone:405-789-7242
Practice Address - Fax:405-495-7562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5518-5518314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100776760AMedicaid
OK100776760AMedicaid