Provider Demographics
NPI:1992930614
Name:SH CCRC, LLC
Entity type:Organization
Organization Name:SH CCRC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MIS
Authorized Official - Prefix:MS
Authorized Official - First Name:DORENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-963-3400
Mailing Address - Street 1:1400 CENTREPARK BLVD STE 810
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-7412
Mailing Address - Country:US
Mailing Address - Phone:239-963-3400
Mailing Address - Fax:239-963-3401
Practice Address - Street 1:5170 S VANDALIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135
Practice Address - Country:US
Practice Address - Phone:918-496-3963
Practice Address - Fax:918-496-0774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-26
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH7227-7227314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100774500AMedicaid
OK375172Medicare Oscar/Certification