NPIMap

Organization Active NPI

Fort Gibson Healthcare, LLC

  • Skilled Nursing Facility
  • Fort Gibson, OK
National Provider Identifier
1063196988
Registry record updated Jun 12, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
FORT GIBSON HEALTHCARE, LLC
Practice address
205 E Poplar St
Fort Gibson, OK 74434-8272
Phone
(918) 478-2456
NPI assigned
Jun 12, 2023
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 12, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Naftali Friedman
Title
Manager
Phone
(314) 631-3000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X Primary

Addresses

Primary practice location

205 E Poplar St
Fort Gibson, OK 74434-8272

Mailing address

477 N Lindbergh Blvd Ste 310
Saint Louis, MO 63141-7856
Phone (314) 631-3000

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OK

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240626001671 OK Part A Provider - Skilled Nursing Facility 7911441480 Practice locations: Fort Gibson, OK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1063196988. Details of each certification follow.

Skilled nursing facility certification: CCN 375330

Legal name
FORT GIBSON HEALTHCARE LLC
Doing business as
FORT GIBSON CARE & REHAB CENTER
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Jan 1, 1998
Last certification
Jan 15, 2025
Beds
66
Ownership / control type
Limited Liability Corporation
Multi-facility organization
MGM Healthcare
Most recent change of ownership
May 14, 2024
Organization structure
LLCProprietary
Incorporated
May 3, 2023 in OK
Enrollment address
205 E Poplar St
Fort Gibson, OK 74434-8272
Nursing home name
FORT GIBSON CARE & REHAB CENTER
Affiliated entity
MGM HEALTHCARE

Care Compare: Nursing home

Medicare Care Compare
Listed as
Fort Gibson Care & Rehab CenterCCN 375330 · All quality measures
Overall star rating
3 of 5
Health inspections
3 of 5
Staffing
2 of 5
Quality measures
4 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
Jan 1, 1998
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
6655.8 residents per day on average
Chain
MGM Healthcare27 facilities in the chain
Penalties (3 years)
2Fines totaling $53,271

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
37D0475184Fort Gibson Care & Rehab Center205 E Poplar, Fort Gibson, OK 74434Certificate of waiverMar 19, 2028

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 8

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Allen Koss Individual Other May 14, 2024 50%
JFB Ok Trust Organization, Saint Louis, MO 5% Or Greater Indirect Ownership Interest May 14, 2024 50%
Ok SNF Holdings, LLC Organization, Saint Louis, MO LLC, Owned by another organization or individual 5% Or Greater Direct Ownership Interest May 14, 2024 50%
Naftali Friedman Individual Corporate OfficerManager May 14, 2024 100%
Ok SNF Investments, LLC Organization, Saint Louis, MO LLC, Owned by another organization or individual 5% Or Greater Direct Ownership Interest May 14, 2024 50%
Southeast Ventures Trust Organization, Lakewood, NJ 5% Or Greater Indirect Ownership Interest May 14, 2024 48%
Yaakov Klein Individual OtherTrustee of Southeast Ventures Trust May 14, 2024 48%
Sara J Smith Individual W-2 Managing EmployeeAd; May 14, 2024 100%

Facilities with the same owner 7

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1686528000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1686528000000",
    "number": "1063196988",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "477 N LINDBERGH BLVD STE 310",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631417856",
            "telephone_number": "314-631-3000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "205 E POPLAR ST",
            "city": "FORT GIBSON",
            "state": "OK",
            "postal_code": "744348272",
            "telephone_number": "918-478-2456"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORT GIBSON HEALTHCARE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-06-12",
        "last_updated": "2023-06-12",
        "certification_date": "2023-06-12",
        "status": "A",
        "authorized_official_last_name": "FRIEDMAN",
        "authorized_official_first_name": "NAFTALI",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "314-631-3000"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Gibson, OK

Sources for this page

Verify at the official NPI Registry.