Basic Information
| Provider Information | |||||||||
| NPI: | 1457349631 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLINGTON HILLS NURSING CENTER INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | WELLINGTON HILLS LIVING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 607 WOODLAND ST | ||||||||
| Address2: | |||||||||
| City: | EUFAULA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744323611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186892508 | ||||||||
| FaxNumber: | 9186892555 | ||||||||
| Practice Location | |||||||||
| Address1: | 607 WOODLAND ST | ||||||||
| Address2: | |||||||||
| City: | EUFAULA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744323611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186892508 | ||||||||
| FaxNumber: | 9186892555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 11/11/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARDY | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | FRANCIS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9186911051 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH4604 | OK | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | NH4604 | OK | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100777410B | 05 | OK | MEDICAID | 000375316001 | 01 | OK | BLUE CROSS BLUE SHIELD | OTHER |