Basic Information
| Provider Information | |||||||||
| NPI: | 1902199714 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONHOLD OF BARTLESVILLE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ADAMS PARC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6006 SE ADAMS BLVD | ||||||||
| Address2: | |||||||||
| City: | BARTLESVILLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740068960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183310550 | ||||||||
| FaxNumber: | 9183310585 | ||||||||
| Practice Location | |||||||||
| Address1: | 6006 SE ADAMS BLVD | ||||||||
| Address2: | |||||||||
| City: | BARTLESVILLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740068960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183310550 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2011 | ||||||||
| LastUpdateDate: | 12/15/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WAKELEY | ||||||||
| AuthorizedOfficialFirstName: | KITT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER, PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 4055501750 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH74006 | OK | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.