=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578655817
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKELAND MANOR INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 604 LAKE MURRAY DR E
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-3851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-223-4501
-----------------------------------------------------
Fax | 580-223-5002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 128
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73402-0128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-490-9200
-----------------------------------------------------
Fax | 580-490-9201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT CEO
-----------------------------------------------------
Name | DR. GARY PORTER
-----------------------------------------------------
Credential | PH.D., J.D., D.PH.
-----------------------------------------------------
Telephone | 580-490-9200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | NH1005-1005
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------