Provider Demographics
NPI:1871529412
Name:HARTSHORNE HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:HARTSHORNE HEALTH SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:M
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-683-9407
Mailing Address - Street 1:1929 BETTY JANE LN
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-1581
Mailing Address - Country:US
Mailing Address - Phone:918-683-9407
Mailing Address - Fax:918-683-1979
Practice Address - Street 1:1300 NORTH DR
Practice Address - Street 2:
Practice Address - City:HARTSHORNE
Practice Address - State:OK
Practice Address - Zip Code:74547-4400
Practice Address - Country:US
Practice Address - Phone:918-297-7000
Practice Address - Fax:918-297-3487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH61116111313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200055510AMedicaid
OK200055510AMedicaid