Healthcare Provider Details

I. General information

NPI: 1033586664
Provider Name (Legal Business Name): COLONIAL PARK MANOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W. FRONTAGE ROAD
OKEMAH OK
74859-6433
US

IV. Provider business mailing address

600 W FRONTAGE RD
OKEMAH OK
74859-6442
US

V. Phone/Fax

Practice location:
  • Phone: 918-623-1936
  • Fax: 918-623-1936
Mailing address:
  • Phone: 918-623-1936
  • Fax: 918-623-2287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH5405-5405
License Number StateOK

VIII. Authorized Official

Name: DONNA SIMMONS
Title or Position: MANAGING MEMBER
Credential: LNHA
Phone: 405-380-6671