Healthcare Provider Details

I. General information

NPI: 1699870329
Provider Name (Legal Business Name): AZALEA PARK MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4717 W OKMULGEE ST
MUSKOGEE OK
74401-4657
US

IV. Provider business mailing address

5800 W OKMULGEE ST
MUSKOGEE OK
74401-4552
US

V. Phone/Fax

Practice location:
  • Phone: 918-683-2914
  • Fax: 918-683-3167
Mailing address:
  • Phone: 918-683-2914
  • Fax: 918-683-3167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH5106-5106
License Number StateOK

VIII. Authorized Official

Name: MIKE DIMOND
Title or Position: MANAGER
Credential:
Phone: 405-943-1144