Basic Information
| Provider Information | |||||||||
| NPI: | 1598856288 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY CARE CENTERS OF OKLAHOMA, LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY CARE CENTER OF KINGSTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | HC 71 BOX 83 | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734399701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805462216 | ||||||||
| FaxNumber: | 5805642298 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 HWY 32 | ||||||||
| Address2: | HC 71 | ||||||||
| City: | KINGSTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734399701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805642216 | ||||||||
| FaxNumber: | 5805642298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 06/21/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | DRENDA | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 9183970007 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH58035803 | OK | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100847060A | 05 | OK | MEDICAID |