Basic Information
| Provider Information | |||||||||
| NPI: | 1225094766 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAGONER CARE CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 N LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | WAGONER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744673915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184852203 | ||||||||
| FaxNumber: | 9184856673 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 N LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | WAGONER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744673915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184852203 | ||||||||
| FaxNumber: | 9184856673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAYNES | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | MDS/CPC | ||||||||
| AuthorizedOfficialTelephone: | 9184852203 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | LPN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH7302-7302 | OK | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.