Provider Demographics
NPI:1164422416
Name:PARKLAND MANOR LIVING CENTER LLC
Entity Type:Organization
Organization Name:PARKLAND MANOR LIVING CENTER LLC
Other - Org Name:PARKLAND MANOR LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-447-3911
Mailing Address - Street 1:200 W PARKLAND
Mailing Address - Street 2:
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864
Mailing Address - Country:US
Mailing Address - Phone:405-567-2201
Mailing Address - Fax:405-567-2395
Practice Address - Street 1:200 W PARKLAND NBU 7407
Practice Address - Street 2:
Practice Address - City:PRAGUE
Practice Address - State:OK
Practice Address - Zip Code:74864
Practice Address - Country:US
Practice Address - Phone:405-567-2201
Practice Address - Fax:405-567-2395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH4103314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100770310AMedicaid
OK100770310AMedicaid