Basic Information
| Provider Information | |||||||||
| NPI: | 1396077236 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONHOLD OF OWASSO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SEQUOYAH POINTE LIVING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 E CHICKASAW AVE | ||||||||
| Address2: | |||||||||
| City: | SALLISAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749554625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187749696 | ||||||||
| FaxNumber: | 9187749797 | ||||||||
| Practice Location | |||||||||
| Address1: | 8515 N 123RD EAST AVE | ||||||||
| Address2: | |||||||||
| City: | OWASSO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740552150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188657701 | ||||||||
| FaxNumber: | 9188657792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2010 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9187749696 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH7242-7242 | OK | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.