Provider Demographics
NPI:1366478786
Name:GREGSTON NURSING HOME INC
Entity type:Organization
Organization Name:GREGSTON NURSING HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-658-2319
Mailing Address - Street 1:711 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MARLOW
Mailing Address - State:OK
Mailing Address - Zip Code:73055-3313
Mailing Address - Country:US
Mailing Address - Phone:580-658-2319
Mailing Address - Fax:580-658-6943
Practice Address - Street 1:711 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MARLOW
Practice Address - State:OK
Practice Address - Zip Code:73055-3313
Practice Address - Country:US
Practice Address - Phone:580-658-2319
Practice Address - Fax:580-658-6943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH69036903313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100773070AMedicaid
OK375425Medicare Oscar/Certification