Provider Demographics
NPI:1124359047
Name:3C OLD FASHION BOARDING HOME
Entity Type:Organization
Organization Name:3C OLD FASHION BOARDING HOME
Other - Org Name:3C OLD FASHION BOARDING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JVON
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-567-7677
Mailing Address - Street 1:719 S JIM THORPE BLVD
Mailing Address - Street 2:NBU 1706
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864-3505
Mailing Address - Country:US
Mailing Address - Phone:405-567-2280
Mailing Address - Fax:405-567-2280
Practice Address - Street 1:719 S JIM THORPE BLVD
Practice Address - Street 2:NBU 1706
Practice Address - City:PRAGUE
Practice Address - State:OK
Practice Address - Zip Code:74864-3505
Practice Address - Country:US
Practice Address - Phone:405-567-2280
Practice Address - Fax:405-567-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness