Healthcare Provider Details

I. General information

NPI: 1124359047
Provider Name (Legal Business Name): 3C OLD FASHION BOARDING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 S JIM THORPE BLVD NBU 1706
PRAGUE OK
74864-3505
US

IV. Provider business mailing address

719 S JIM THORPE BLVD NBU 1706
PRAGUE OK
74864-3505
US

V. Phone/Fax

Practice location:
  • Phone: 405-567-2280
  • Fax: 405-567-2280
Mailing address:
  • Phone: 405-567-2280
  • Fax: 405-567-2280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateOK

VIII. Authorized Official

Name: JVON COOK
Title or Position: OWNER
Credential:
Phone: 405-567-7677