1669469755 NPI number — COLONIAL TERRACE NURSING CARE CENTER LLC

Table of content: SHANNON ANN BROWN MD (NPI 1104965110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669469755 NPI number — COLONIAL TERRACE NURSING CARE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLONIAL TERRACE NURSING CARE CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COLONIAL TERRACE CARE CTR
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669469755
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 N ELM ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
SALLISAW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74955-4633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-775-6200
Provider Business Mailing Address Fax Number:
918-775-5643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1320 NE 1ST PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRYOR
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74361-4406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-825-5311
Provider Business Practice Location Address Fax Number:
918-825-4439
Provider Enumeration Date:
10/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
VP IN CHARGE OF REIMBURSEMENT
Authorized Official Telephone Number:
918-775-6200

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  314000000X , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100777360A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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