Healthcare Provider Details

I. General information

NPI: 1336132539
Provider Name (Legal Business Name): SENIOR VILLAGE NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 N MADISON AVE
BLANCHARD OK
73010-6504
US

IV. Provider business mailing address

1104 N MADISON AVE
BLANCHARD OK
73010-6504
US

V. Phone/Fax

Practice location:
  • Phone: 405-485-3315
  • Fax:
Mailing address:
  • Phone: 405-485-3315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH4403-4403
License Number StateOK

VIII. Authorized Official

Name: MR. BOBBY VERNON SIMMONS
Title or Position: MANAGER
Credential: D.PH
Phone: 405-360-2562