=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497723621
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CPC-SHERWOOD MANOR, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2006
-----------------------------------------------------
Last Update Date | 05/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2416 W 51ST ST
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74107-7700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-446-4284
-----------------------------------------------------
Fax | 918-445-8811
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2416 W 51ST ST
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74107-7700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-446-4284
-----------------------------------------------------
Fax | 918-445-8811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGIONAL DIRECTOR
-----------------------------------------------------
Name | MR. KEVIN BRADLEY POUND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 228-861-7598
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | NH72257225
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------