Provider Demographics
NPI:1992704852
Name:PERRY GREEN VALLEY NURSING HOME INC
Entity type:Organization
Organization Name:PERRY GREEN VALLEY NURSING HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:DUEHNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-282-6285
Mailing Address - Street 1:1103 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:OK
Mailing Address - Zip Code:73077-6269
Mailing Address - Country:US
Mailing Address - Phone:580-336-2285
Mailing Address - Fax:580-336-3445
Practice Address - Street 1:1103 BIRCH ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OK
Practice Address - Zip Code:73077-6269
Practice Address - Country:US
Practice Address - Phone:580-336-2285
Practice Address - Fax:580-336-3445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5202314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375373Medicare ID - Type Unspecified