=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336132539
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SENIOR VILLAGE NURSING HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2005
-----------------------------------------------------
Last Update Date | 07/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1104 N MADISON AVE
-----------------------------------------------------
City | BLANCHARD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73010-6504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-485-3315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1104 N MADISON AVE
-----------------------------------------------------
City | BLANCHARD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73010-6504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-485-3315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. BOBBY VERNON SIMMONS
-----------------------------------------------------
Credential | D.PH
-----------------------------------------------------
Telephone | 405-360-2562
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | NH4403-4403
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------