Healthcare Provider Details

I. General information

NPI: 1477308534
Provider Name (Legal Business Name): HERITAGE PARK MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6912 NW 23RD ST
BETHANY OK
73008-5219
US

IV. Provider business mailing address

617 S AIR DEPOT BLVD
MIDWEST CITY OK
73110-4426
US

V. Phone/Fax

Practice location:
  • Phone: 405-789-7208
  • Fax:
Mailing address:
  • Phone: 405-556-5333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ADAMSON UNDERWOOD
Title or Position: CEO
Credential:
Phone: 405-556-5333