Healthcare Provider Details

I. General information

NPI: 1821093352
Provider Name (Legal Business Name): PSG - WILLOW PARK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7019 NW CACHE RD
LAWTON OK
73505-2707
US

IV. Provider business mailing address

7019 NW CACHE RD
LAWTON OK
73505-2707
US

V. Phone/Fax

Practice location:
  • Phone: 580-536-1279
  • Fax: 580-510-0017
Mailing address:
  • Phone: 580-536-1279
  • Fax: 580-510-0017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH 16071607
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH1607-1607
License Number StateOK

VIII. Authorized Official

Name: MRS. CHERYL HANKINS
Title or Position: ADMINISTRATOR
Credential:
Phone: 580-536-1279