Provider Demographics
NPI:1417058470
Name:EASTWOOD MANOR, LLC
Entity Type:Organization
Organization Name:EASTWOOD MANOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-775-4439
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-0429
Mailing Address - Country:US
Mailing Address - Phone:918-775-4439
Mailing Address - Fax:918-775-9242
Practice Address - Street 1:519 N MICKEY MANTLE BLVD
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:OK
Practice Address - Zip Code:74339-1127
Practice Address - Country:US
Practice Address - Phone:918-675-4455
Practice Address - Fax:918-675-5472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5802-5802313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200081000AMedicaid