Basic Information
| Provider Information | |||||||||
| NPI: | 1881775070 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HILLDALE NURSING FACILITY, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COWETA MANOR NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 490 | ||||||||
| Address2: | |||||||||
| City: | COWETA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744290490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184862166 | ||||||||
| FaxNumber: | 9184866308 | ||||||||
| Practice Location | |||||||||
| Address1: | 30049 E 151ST STREET SOUTH | ||||||||
| Address2: | |||||||||
| City: | COWETA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184862166 | ||||||||
| FaxNumber: | 9184866308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHANKLE | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9184862166 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH7301-7301 | OK | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.