Provider Demographics
NPI:1245228238
Name:SILVERCREST MANOR NURSING HOME INC
Entity Type:Organization
Organization Name:SILVERCREST MANOR NURSING HOME INC
Other - Org Name:LEGACY LIVING CENTERS
Other - Org Type:Other Name
Authorized Official - Title/Position:INSURANCE/MEDICARE
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:PITA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-622-6300
Mailing Address - Street 1:301 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ANADARKO
Mailing Address - State:OK
Mailing Address - Zip Code:73005-2442
Mailing Address - Country:US
Mailing Address - Phone:405-247-3346
Mailing Address - Fax:405-247-5635
Practice Address - Street 1:301 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ANADARKO
Practice Address - State:OK
Practice Address - Zip Code:73005-2442
Practice Address - Country:US
Practice Address - Phone:405-247-3346
Practice Address - Fax:405-247-5635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH0805-0805313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000375477001OtherBLUE CROSS BLUE SHIELD OK
OK200059970AMedicaid
OK200059970AMedicaid