Basic Information
| Provider Information | |||||||||
| NPI: | 1770735862 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROMISE HARRAH LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HARRAH NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 WHITES MEADOW DR | ||||||||
| Address2: | |||||||||
| City: | HARRAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730459402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054546255 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2400 WHITES MEADOW DR | ||||||||
| Address2: | |||||||||
| City: | HARRAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730459402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054546255 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 03/18/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4055737908 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH5551-5551 | OK | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.