Basic Information
| Provider Information | |||||||||
| NPI: | 1205824463 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRESCENT MANOR INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CRESCENT CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 208 E SANDERSON ST | ||||||||
| Address2: | |||||||||
| City: | CRESCENT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730289027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056962698 | ||||||||
| FaxNumber: | 4059692327 | ||||||||
| Practice Location | |||||||||
| Address1: | 208 E SANDERSON ST | ||||||||
| Address2: | |||||||||
| City: | CRESCENT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730289027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056962698 | ||||||||
| FaxNumber: | 4059692327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 01/24/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORGAN | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4797695535 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH4202-4202 | OK | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 000375480001 | 01 | OK | BLUE CROSS BLUE SHIELD OK | OTHER | 200055460A | 05 | OK | MEDICAID |