Healthcare Provider Details

I. General information

NPI: 1871892109
Provider Name (Legal Business Name): CONHOLD OF PONCA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2011
Last Update Date: 03/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2024 TURNER ROAD
PONCA CITY OK
74601
US

IV. Provider business mailing address

111 EAST CHICKASAW
SALLISAW OK
74955-0767
US

V. Phone/Fax

Practice location:
  • Phone: 580-765-3364
  • Fax: 580-765-3376
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 Number
License Number State

VIII. Authorized Official

Name: MR. JAMES FRANKLIN SULLIVAN JR.
Title or Position: MANAGER/OWNER
Credential: J.D.
Phone: 918-774-9696