Healthcare Provider Details

I. General information

NPI: 1225038524
Provider Name (Legal Business Name): ELMWOOD MANOR NURSING HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S SEMINOLE AVE
WEWOKA OK
74884-2557
US

IV. Provider business mailing address

PO BOX 975
WEWOKA OK
74884-0975
US

V. Phone/Fax

Practice location:
  • Phone: 405-257-6621
  • Fax: 405-257-6402
Mailing address:
  • Phone: 405-257-6621
  • Fax: 405-257-6402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH6701-6701
License Number StateOK

VIII. Authorized Official

Name: PAM HUMPHREYS
Title or Position: OWNER
Credential:
Phone: 405-379-0039