Provider Demographics
NPI:1912960089
Name:SHEPHERD'S CARE HOSPICE OF WAGONER, LLC
Entity Type:Organization
Organization Name:SHEPHERD'S CARE HOSPICE OF WAGONER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEENA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOTTOM
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MS ,CHN
Authorized Official - Phone:918-485-4673
Mailing Address - Street 1:611 W CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-4618
Mailing Address - Country:US
Mailing Address - Phone:918-485-4673
Mailing Address - Fax:
Practice Address - Street 1:611 W CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4618
Practice Address - Country:US
Practice Address - Phone:918-485-4673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4177251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK371631Medicare Oscar/Certification