Provider Demographics
NPI:1467750976
Name:COLONIAL PARK NURSING HOME INC
Entity Type:Organization
Organization Name:COLONIAL PARK NURSING HOME INC
Other - Org Name:COLONIAL PARK NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-380-6902
Mailing Address - Street 1:131 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-5003
Mailing Address - Country:US
Mailing Address - Phone:580-436-0950
Mailing Address - Fax:580-436-0953
Practice Address - Street 1:600 W FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:OKEMAH
Practice Address - State:OK
Practice Address - Zip Code:74859-6433
Practice Address - Country:US
Practice Address - Phone:918-623-1936
Practice Address - Fax:918-623-2287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5405-5405313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility