Provider Demographics
NPI:1053317107
Name:PSG TEMPLE LLC
Entity Type:Organization
Organization Name:PSG TEMPLE LLC
Other - Org Name:TEMPLE MANOR NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUCRETIA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PARKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-342-6228
Mailing Address - Street 1:100 GREEN AVENUE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:OK
Mailing Address - Zip Code:73568
Mailing Address - Country:US
Mailing Address - Phone:580-342-6228
Mailing Address - Fax:580-342-5015
Practice Address - Street 1:100 GREEN AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:OK
Practice Address - Zip Code:73568
Practice Address - Country:US
Practice Address - Phone:580-342-6228
Practice Address - Fax:580-342-5015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH1702314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200102030AMedicaid
OK200055110CMedicaid
OK375429Medicare ID - Type UnspecifiedMEDICARE PROVIDER #