MEDICARE: SENIOR VILLAGE NURSING HOME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	NH4403-4403	OK

General Provider Information

NPI Number	:	1336132539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SENIOR VILLAGE NURSING HOME

Provider Business Mailing Address
First Line	:	1104 N MADISON AVE
Second Line	:
City	:	BLANCHARD
State	:	OK
Zip	:	73010-6504
Country	:	US
Telephone Number	:	405-485-3315
Fax Number	:

Provider Business Practice Location Address
First Line	:	1104 N MADISON AVE
Second Line	:
City	:	BLANCHARD
State	:	OK
Zip	:	73010-6504
Country	:	US
Telephone Number	:	405-485-3315
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. BOBBY VERNON SIMMONS
Credential	:	D.PH
Telephone Number	:	405-360-2562

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	07/01/2008

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