Healthcare Provider Details

I. General information

NPI: 1245571165
Provider Name (Legal Business Name): HEARTSWORTH SENIOR LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2013
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W CANADIAN AVE
VINITA OK
74301-2702
US

IV. Provider business mailing address

PO BOX 990
EDMOND OK
73083-0990
US

V. Phone/Fax

Practice location:
  • Phone: 918-256-8768
  • Fax:
Mailing address:
  • Phone: 405-285-8166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH1802--1802
License Number StateOK

VIII. Authorized Official

Name: LEE PILGRIM
Title or Position: MEMBER
Credential:
Phone: 405-285-8166