Basic Information
| Provider Information | |||||||||
| NPI: | 1477533487 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PF SOUTH YUKON SNF OPS, LLC | ||||||||
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| OtherOrganizationName: | RANCHWOOD NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 WATERS RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | LEWISVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750576011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728994401 | ||||||||
| FaxNumber: | 9728994806 | ||||||||
| Practice Location | |||||||||
| Address1: | 824 S YUKON PKWY | ||||||||
| Address2: | |||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730994584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053542022 | ||||||||
| FaxNumber: | 4053548461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHANCE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2147252837 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH5604-5604 | OK | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 200060680A | 05 | OK | MEDICAID |