Basic Information
Provider Information | |||||||||
NPI: | 1871892109 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CONHOLD OF PONCA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 111 EAST CHICKASAW | ||||||||
Address2: |   | ||||||||
City: | SALLISAW | ||||||||
State: | OK | ||||||||
PostalCode: | 749550767 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9187749696 | ||||||||
FaxNumber: | 9187749797 | ||||||||
Practice Location | |||||||||
Address1: | 2024 TURNER ROAD | ||||||||
Address2: |   | ||||||||
City: | PONCA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 74601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5807653364 | ||||||||
FaxNumber: | 5807653376 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/25/2011 | ||||||||
LastUpdateDate: | 03/25/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SULLIVAN | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | FRANKLIN | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER/OWNER | ||||||||
AuthorizedOfficialTelephone: | 9187749696 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | J.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | NH3607-3607 | 01 | OK | STATE LICENSE NUMBER | OTHER |