Healthcare Provider Details

I. General information

NPI: 1497086979
Provider Name (Legal Business Name): CONHOLD OF MANNFORD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 E CIMARRON
MANNFORD OK
74044
US

IV. Provider business mailing address

111 E CHICKASAW AVE
SALLISAW OK
74955-4625
US

V. Phone/Fax

Practice location:
  • Phone: 918-865-7701
  • Fax: 918-774-9797
Mailing address:
  • Phone: 918-774-9696
  • Fax: 918-774-9797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH1907-1907
License Number StateOK

VIII. Authorized Official

Name: MR. JAMES F SULLIVAN JR.
Title or Position: OWNER
Credential:
Phone: 918-774-9696