Basic Information
| Provider Information | |||||||||
| NPI: | 1538256698 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SILVER LAKE CARE CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CCLS, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6006 SE ADAMS BLVD | ||||||||
| Address2: | |||||||||
| City: | BARTLESVILLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740068960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183352172 | ||||||||
| FaxNumber: | 9183334967 | ||||||||
| Practice Location | |||||||||
| Address1: | 6006 SE ADAMS BLVD | ||||||||
| Address2: | |||||||||
| City: | BARTLESVILLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740068960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183352172 | ||||||||
| FaxNumber: | 9183334967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 02/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | PARISH | ||||||||
| AuthorizedOfficialFirstName: | MELVA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CPA | ||||||||
| AuthorizedOfficialTelephone: | 9183352172 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH7406-7406 | OK | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.