Healthcare Provider Details

I. General information

NPI: 1205824463
Provider Name (Legal Business Name): CRESCENT MANOR INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 01/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 E SANDERSON ST
CRESCENT OK
73028-9027
US

IV. Provider business mailing address

208 E SANDERSON ST
CRESCENT OK
73028-9027
US

V. Phone/Fax

Practice location:
  • Phone: 405-696-2698
  • Fax: 405-969-2327
Mailing address:
  • Phone: 405-696-2698
  • Fax: 405-969-2327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH4202-4202
License Number StateOK

VIII. Authorized Official

Name: BRANDON MORGAN
Title or Position: CEO
Credential:
Phone: 479-769-5535