MEDICARE: HERITAGE MANOR MANAGEMENT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1679328728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE MANOR MANAGEMENT, LLC

Provider Business Mailing Address
First Line	:	617 S AIR DEPOT BLVD
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-4426
Country	:	US
Telephone Number	:	405-556-5333
Fax Number	:

Provider Business Practice Location Address
First Line	:	3804 N BARR AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73122-2410
Country	:	US
Telephone Number	:	405-789-7103
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. ADAMSON UNDERWOOD
Credential	:
Telephone Number	:	405-556-5333

Provider Enumeration Date	:	04/22/2024
Last Update Date	:	04/22/2024

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Directions to “HERITAGE MANOR MANAGEMENT, LLC ” Practice Location

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