Basic Information
| Provider Information | |||||||||
| NPI: | 1568768000 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RECEIVER CARE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HARRAH NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 119 N ROBINSON AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731024613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052720511 | ||||||||
| FaxNumber: | 4052720501 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 WHITES MEADOW DR | ||||||||
| Address2: | |||||||||
| City: | HARRAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730459402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054546255 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2011 | ||||||||
| LastUpdateDate: | 05/13/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAYNE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | RECEIVER | ||||||||
| AuthorizedOfficialTelephone: | 4052720511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH5551 | OK | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 200317210C | 05 | OK | MEDICAID |