Provider Demographics
NPI:1053437251
Name:JAMES DENNIS MEDICAL FOUNDATION INC
Entity type:Organization
Organization Name:JAMES DENNIS MEDICAL FOUNDATION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-594-2292
Mailing Address - Street 1:1153 CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:WAKITA
Mailing Address - State:OK
Mailing Address - Zip Code:73771-9520
Mailing Address - Country:US
Mailing Address - Phone:580-594-2292
Mailing Address - Fax:580-594-2534
Practice Address - Street 1:1153 CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:WAKITA
Practice Address - State:OK
Practice Address - Zip Code:73771-5095
Practice Address - Country:US
Practice Address - Phone:580-594-2292
Practice Address - Fax:580-594-2534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH2701-2701314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375290Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
OK375290Medicare Oscar/Certification