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General NPI Number Information
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NPI Number | 1174941496
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Entity Type | Organization
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Legal Business Name | HEAVENER MANOR, LLC
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Dates
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Enumeration Date | 04/03/2014
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Last Update Date | 06/07/2024
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Provider Practice Location Address
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Address Line | 204 W 1ST ST
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City | HEAVENER
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State | OK
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Zip | 74937-2062
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Country | US
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Telephone | 918-653-2034
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Fax | 918-653-4518
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Provider Business Mailing Address
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Address Line | 9 PROFESSIONAL DR
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City | BELLA VISTA
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State | AR
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Zip | 72715-8462
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Country | US
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Telephone | 479-259-5558
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | BRADFORD MONTGOMERY
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Credential |
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Telephone | 479-250-5558
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | NH4001-4001
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License Number State | OK
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