Basic Information
Provider Information | |||||||||
NPI: | 1497086979 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CONHOLD OF MANNFORD LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CIMARRON POINTE CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 111 E CHICKASAW AVE | ||||||||
Address2: |   | ||||||||
City: | SALLISAW | ||||||||
State: | OK | ||||||||
PostalCode: | 749554625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9187749696 | ||||||||
FaxNumber: | 9187749797 | ||||||||
Practice Location | |||||||||
Address1: | 404 E CIMARRON | ||||||||
Address2: |   | ||||||||
City: | MANNFORD | ||||||||
State: | OK | ||||||||
PostalCode: | 74044 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9188657701 | ||||||||
FaxNumber: | 9187749797 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/22/2010 | ||||||||
LastUpdateDate: | 05/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
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 | NH1907-1907 | OK | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.