Basic Information
| Provider Information | |||||||||
| NPI: | 1770956625 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRACEWOOD HEALTH & REHAB LLC | ||||||||
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| OtherOrganizationName: | GRACEWOOD HEALTH & REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | BELLA VISTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727158462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797156759 | ||||||||
| FaxNumber: | 4797156922 | ||||||||
| Practice Location | |||||||||
| Address1: | 6201 E 36TH ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741355810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186223430 | ||||||||
| FaxNumber: | 9186220626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2015 | ||||||||
| LastUpdateDate: | 05/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | MONTGOMERY | ||||||||
| AuthorizedOfficialFirstName: | BRADFORD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4797156759 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH7229 | OK | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.