Healthcare Provider Details

I. General information

NPI: 1831172857
Provider Name (Legal Business Name): SKYLINE HEIGHTS OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6202 E 61ST ST
TULSA OK
74136-2119
US

IV. Provider business mailing address

16 NORCROSS ST STE 100
ROSWELL GA
30075-3810
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-8820
  • Fax: 918-494-8837
Mailing address:
  • Phone: 770-255-1810
  • Fax: 770-255-0059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH72267226
License Number StateOK

VIII. Authorized Official

Name: MR. ROBERT DANIEL VAUGHAN
Title or Position: CEO
Credential:
Phone: 770-255-1810