Healthcare Provider Details

I. General information

NPI: 1255425898
Provider Name (Legal Business Name): TIMBERLANE MANOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 SOUTH RANKIN
EDMOND OK
73013
US

IV. Provider business mailing address

2520 SOUTH RANKIN
EDMOND OK
73013
US

V. Phone/Fax

Practice location:
  • Phone: 405-341-1433
  • Fax: 405-562-2128
Mailing address:
  • Phone: 405-341-1433
  • Fax: 405-562-2128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH5536-5536
License Number StateOK

VIII. Authorized Official

Name: KRISTY DEROIN
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential: MBA
Phone: 405-943-1144