Provider Demographics
NPI:1215926928
Name:SCG DURANT FOUR SEASONS LLC
Entity type:Organization
Organization Name:SCG DURANT FOUR SEASONS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-341-2700
Mailing Address - Street 1:1240 MARBELLA PLAZA DR.
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-7905
Mailing Address - Country:US
Mailing Address - Phone:813-341-2700
Mailing Address - Fax:813-676-0127
Practice Address - Street 1:1212 FOUR SEASONS DR
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2430
Practice Address - Country:US
Practice Address - Phone:580-924-5300
Practice Address - Fax:580-924-1302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH0704-0704314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100769540AMedicaid
OK375238Medicare Oscar/Certification
OK1194980001Medicare NSC