Provider Demographics
NPI:1770735862
Name:PROMISE HARRAH LLC
Entity type:Organization
Organization Name:PROMISE HARRAH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-573-7908
Mailing Address - Street 1:2400 WHITES MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:HARRAH
Mailing Address - State:OK
Mailing Address - Zip Code:73045-9402
Mailing Address - Country:US
Mailing Address - Phone:405-454-6255
Mailing Address - Fax:
Practice Address - Street 1:2400 WHITES MEADOW DR
Practice Address - Street 2:
Practice Address - City:HARRAH
Practice Address - State:OK
Practice Address - Zip Code:73045-9402
Practice Address - Country:US
Practice Address - Phone:405-454-6255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5551-5551314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK37 5405Medicare PIN
OK375405Medicare Oscar/Certification