Provider Demographics
NPI:1346385689
Name:LIGHTNING CREEK INVESTMENT GROUP INC
Entity Type:Organization
Organization Name:LIGHTNING CREEK INVESTMENT GROUP INC
Other - Org Name:MOORELAND HERITAGE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:MADDUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-273-3649
Mailing Address - Street 1:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:NOWATA
Mailing Address - State:OK
Mailing Address - Zip Code:74048-0468
Mailing Address - Country:US
Mailing Address - Phone:918-273-3649
Mailing Address - Fax:918-273-5652
Practice Address - Street 1:402 SE 6TH ST
Practice Address - Street 2:
Practice Address - City:MOORELAND
Practice Address - State:OK
Practice Address - Zip Code:73852-9064
Practice Address - Country:US
Practice Address - Phone:918-273-3649
Practice Address - Fax:918-273-5652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH7702-7702313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100776120BMedicaid