Basic Information
| Provider Information | |||||||||
| NPI: | 1427046796 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENNESSEY MANOR NURSING HOME INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LEGACY LIVING CENTERS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | HENNESSEY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737421620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058536027 | ||||||||
| FaxNumber: | 4058534389 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | HENNESSEY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737421620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058536027 | ||||||||
| FaxNumber: | 4058534389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PITA | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE/MEDICARE | ||||||||
| AuthorizedOfficialTelephone: | 5806226300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH3703-3703 | OK | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 731473404001 | 01 | OK | BLUE CROSS BLUE SHIELD OK | OTHER | 200059260A | 05 | OK | MEDICAID |