Basic Information
| Provider Information | |||||||||
| NPI: | 1588704860 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MITCHELL MANOR CONVALESCENT HOME LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 W ELECTRIC AVE | ||||||||
| Address2: | |||||||||
| City: | MCALESTER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745013600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184234661 | ||||||||
| FaxNumber: | 9184238382 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 W ELECTRIC AVE | ||||||||
| Address2: | |||||||||
| City: | MCALESTER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745013600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184234661 | ||||||||
| FaxNumber: | 9184238382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 07/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | NIVA | ||||||||
| AuthorizedOfficialMiddleName: | JO | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9184234661 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH6104-6104 | OK | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 100774320A | 05 | OK | MEDICAID |