Basic Information
| Provider Information | |||||||||
| NPI: | 1245228238 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SILVERCREST MANOR NURSING HOME INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LEGACY LIVING CENTERS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 301 W WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ANADARKO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730052442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052473346 | ||||||||
| FaxNumber: | 4052475635 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 W WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ANADARKO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730052442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052473346 | ||||||||
| FaxNumber: | 4052475635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PITA | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE/MEDICARE | ||||||||
| AuthorizedOfficialTelephone: | 5806226300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH0805-0805 | OK | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 000375477001 | 01 | OK | BLUE CROSS BLUE SHIELD OK | OTHER | 200059970A | 05 | OK | MEDICAID |