1285724732 NPI number — HERITAGE VILLAGE NURSING CENTER LLC

Table of content: (NPI 1285724732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285724732 NPI number — HERITAGE VILLAGE NURSING CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE VILLAGE NURSING 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:
Provider Other Organization Name Type Code:
6
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:
1285724732
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 HIGHWAY 48 NORTH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLDENVILLE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74848
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-379-6671
Provider Business Mailing Address Fax Number:
405-379-6674

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 HIGHWAY 48 NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLDENVILLE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-379-6671
Provider Business Practice Location Address Fax Number:
405-379-6674
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SIMMONS
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
405-379-6671

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH3205-3205 , 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: 100777930A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200111530A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com