Basic Information
| Provider Information | |||||||||
| NPI: | 1073709176 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | C.H.R.E L.L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COWETA MANOR NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 490 | ||||||||
| Address2: | 30049 E. 151ST ST. SOUTH | ||||||||
| City: | COWETA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184862166 | ||||||||
| FaxNumber: | 9184866308 | ||||||||
| Practice Location | |||||||||
| Address1: | 30049 E. 151ST ST. SOUTH | ||||||||
| Address2: | |||||||||
| City: | COWETA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184862166 | ||||||||
| FaxNumber: | 9184862166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2007 | ||||||||
| LastUpdateDate: | 04/14/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | NORMA | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9186192204 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH7301 | OK | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | OK | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.