Healthcare Provider Details

I. General information

NPI: 1164422416
Provider Name (Legal Business Name): PARKLAND MANOR LIVING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W PARKLAND NBU 7407
PRAGUE OK
74864
US

IV. Provider business mailing address

200 W PARKLAND
PRAGUE OK
74864
US

V. Phone/Fax

Practice location:
  • Phone: 405-567-2201
  • Fax: 405-567-2395
Mailing address:
  • Phone: 405-567-2201
  • Fax: 405-567-2395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH4103
License Number StateOK

VIII. Authorized Official

Name: MISS JULIE JUSTICE
Title or Position: MANAGING MEMBER
Credential:
Phone: 405-447-3911