Healthcare Provider Details

I. General information

NPI: 1962503318
Provider Name (Legal Business Name): COLONIAL PLAZA NURSING HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S LINWOOD AVE
CUSHING OK
74023-4644
US

IV. Provider business mailing address

530 S LINWOOD AVE
CUSHING OK
74023-4644
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-7838
  • Fax:
Mailing address:
  • Phone: 918-743-7838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number0004362
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number375471
License Number StateOK

VIII. Authorized Official

Name: ED RUCKER
Title or Position: ADMISTRATOR
Credential:
Phone: 918-743-7838