Basic Information
| Provider Information | |||||||||
| NPI: | 1407844533 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARLOW MANOR NURSING HOME INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LEGACY LIVING CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 702 S 9TH ST | ||||||||
| Address2: | |||||||||
| City: | MARLOW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730553226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5806585468 | ||||||||
| FaxNumber: | 5806583669 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 S 9TH ST | ||||||||
| Address2: | |||||||||
| City: | MARLOW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730553226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5806585468 | ||||||||
| FaxNumber: | 5806583669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 06/16/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PITA | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE/MEDICARE | ||||||||
| AuthorizedOfficialTelephone: | 5806226300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH6907-6907 | OK | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 200055070A | 05 | OK | MEDICAID | 000375490001 | 01 | OK | BLUE CROSS BLUE SHIELD OK | OTHER |