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General NPI Number Information
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NPI Number | 1366195018
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Entity Type | Organization
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Legal Business Name | PARKER PLACE HOME 1, LLC.
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Dates
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Enumeration Date | 02/02/2022
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Last Update Date | 02/02/2022
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Provider Practice Location Address
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Address Line | 7514 NW SUN BLVD.
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City | LAWTON
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State | OK
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Zip | 73505
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Country | US
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Telephone | 940-337-6777
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Fax |
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Provider Business Mailing Address
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Address Line | 7514 NW SUN BLVD.
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City | LAWTON
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State | OK
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Zip | 73505
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Country | US
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Telephone | 940-337-6777
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Fax |
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Authorized Official
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Title or Position | OWNER/ADMINISTRATOR
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Name | SALLY HEATHER CLEMENT
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Credential | LNHA
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Telephone | 940-337-6777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number |
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License Number State |
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