Basic Information
| Provider Information | |||||||||
| NPI: | 1740404409 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIKE BUSSEY, RECEIVER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUNSET ESTATES OF EL RENO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1380 S. DOUGLAS BLVD. | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731305215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057370881 | ||||||||
| FaxNumber: | 4057370899 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 TOWNSEND DR | ||||||||
| Address2: | |||||||||
| City: | EL RENO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730362116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052623323 | ||||||||
| FaxNumber: | 4052623328 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCENTIRE | ||||||||
| AuthorizedOfficialFirstName: | S. | ||||||||
| AuthorizedOfficialMiddleName: | WENDY | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4057370881 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 06049 | OK | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 20008750A | 05 | OK | MEDICAID |