Provider Demographics
NPI:1144326489
Name:REBOLD MANOR L L C
Entity type:Organization
Organization Name:REBOLD MANOR L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROIN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:405-943-1144
Mailing Address - Street 1:1701 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-4807
Mailing Address - Country:US
Mailing Address - Phone:918-756-1967
Mailing Address - Fax:918-756-4271
Practice Address - Street 1:1701 E 6TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-4807
Practice Address - Country:US
Practice Address - Phone:918-756-1967
Practice Address - Fax:918-756-4271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5608-5608314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200073640AMedicaid