Provider Demographics
NPI:1346314572
Name:KENWOOD MANOR LLC
Entity Type:Organization
Organization Name:KENWOOD MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NADER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-786-2276
Mailing Address - Street 1:502 W PINE AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-3032
Mailing Address - Country:US
Mailing Address - Phone:580-233-2722
Mailing Address - Fax:
Practice Address - Street 1:502 W PINE AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-3032
Practice Address - Country:US
Practice Address - Phone:580-233-2722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENWOOD MANOR LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-20
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH2406-2406314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200059530AMedicaid
OK375459Medicare ID - Type Unspecified