Provider Demographics
NPI:1407844533
Name:MARLOW MANOR NURSING HOME INC
Entity Type:Organization
Organization Name:MARLOW MANOR NURSING HOME INC
Other - Org Name:LEGACY LIVING CENTERS
Other - Org Type:Doing Business As
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 1:702 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:MARLOW
Mailing Address - State:OK
Mailing Address - Zip Code:73055-3226
Mailing Address - Country:US
Mailing Address - Phone:580-658-5468
Mailing Address - Fax:580-658-3669
Practice Address - Street 1:702 S 9TH ST
Practice Address - Street 2:
Practice Address - City:MARLOW
Practice Address - State:OK
Practice Address - Zip Code:73055-3226
Practice Address - Country:US
Practice Address - Phone:580-658-5468
Practice Address - Fax:580-658-3669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH6907-6907313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200055070AMedicaid
OK000375490001OtherBLUE CROSS BLUE SHIELD OK
OK200055070AMedicaid