# GRAND LAKE VILLA LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1740354893
- **Authorized official:** MICHELINE NADER (OWNER)
- **Authorized official phone:** (918) 786-2276

## Contact information

- **Practice address:** 103 W 13TH ST, GROVE, OK 74344-3224
- **Practice address phone:** (918) 786-2276
- **Mailing address:** 103 W 13TH ST, GROVE, OK 74344-3224
- **Mailing address phone:** (918) 786-2276

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | NH 2102-2102 | OK | Yes |

## Other

- **Enumeration date:** 11/20/2006
- **Last updated:** 09/16/2011

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 200059540A | — | OK |