Provider Demographics
NPI:1205824463
Name:CRESCENT MANOR INC.
Entity Type:Organization
Organization Name:CRESCENT MANOR INC.
Other - Org Name:CRESCENT CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-769-5535
Mailing Address - Street 1:208 E SANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:CRESCENT
Mailing Address - State:OK
Mailing Address - Zip Code:73028-9027
Mailing Address - Country:US
Mailing Address - Phone:405-696-2698
Mailing Address - Fax:405-969-2327
Practice Address - Street 1:208 E SANDERSON ST
Practice Address - Street 2:
Practice Address - City:CRESCENT
Practice Address - State:OK
Practice Address - Zip Code:73028-9027
Practice Address - Country:US
Practice Address - Phone:405-696-2698
Practice Address - Fax:405-969-2327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH4202-4202313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000375480001OtherBLUE CROSS BLUE SHIELD OK
OK200055460AMedicaid
OK200055460AMedicaid