Provider Demographics
NPI:1528159266
Name:BLUE RIVER HEALTHCARE INC.
Entity type:Organization
Organization Name:BLUE RIVER HEALTHCARE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VETRESS
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-371-2636
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-0157
Mailing Address - Country:US
Mailing Address - Phone:580-371-2636
Mailing Address - Fax:580-371-3890
Practice Address - Street 1:1105 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-2401
Practice Address - Country:US
Practice Address - Phone:580-371-2636
Practice Address - Fax:580-371-3890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH35013501313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375302Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER