Provider Demographics
NPI:1104151877
Name:CHISHOLM TRAIL RETIREMENT COMMUNITY
Entity type:Organization
Organization Name:CHISHOLM TRAIL RETIREMENT COMMUNITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:REX
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-470-8600
Mailing Address - Street 1:625 CHISHOLM TRAIL PKWY
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-2205
Mailing Address - Country:US
Mailing Address - Phone:580-470-8600
Mailing Address - Fax:
Practice Address - Street 1:625 CHISHOLM TRAIL PKWY
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-2205
Practice Address - Country:US
Practice Address - Phone:580-470-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAL 6903-6903310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility