Basic Information
| Provider Information | |||||||||
| NPI: | 1801287982 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN HILLS REHAB CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHERN HILLS REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5170 S VANDALIA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741354079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184963963 | ||||||||
| FaxNumber: | 9184960774 | ||||||||
| Practice Location | |||||||||
| Address1: | 5170 S VANDALIA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741354079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184963963 | ||||||||
| FaxNumber: | 9184960774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2015 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BALLER | ||||||||
| AuthorizedOfficialFirstName: | LANCE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3034492100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 200609790B | 05 | OK | MEDICAID | 200609790A | 05 | OK | MEDICAID |