Healthcare Provider Details

I. General information

NPI: 1700885787
Provider Name (Legal Business Name): BROADWAY MANOR MANAGEMENT L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 E BROADWAY ST
MUSKOGEE OK
74403-4601
US

IV. Provider business mailing address

1622 E BROADWAY ST
MUSKOGEE OK
74403-4601
US

V. Phone/Fax

Practice location:
  • Phone: 918-683-2851
  • Fax: 918-683-2992
Mailing address:
  • Phone: 918-683-2851
  • Fax: 918-683-2992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MICHAEL THORNTON SCOTT
Title or Position: MANAGING MEMBER
Credential:
Phone: 918-683-2851