Provider Demographics
NPI:1578655817
Name:LAKELAND MANOR INC
Entity Type:Organization
Organization Name:LAKELAND MANOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, JD, DPH
Authorized Official - Phone:580-490-9200
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-0128
Mailing Address - Country:US
Mailing Address - Phone:580-490-9200
Mailing Address - Fax:580-490-9201
Practice Address - Street 1:604 LAKE MURRAY DR E
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-3851
Practice Address - Country:US
Practice Address - Phone:580-223-4501
Practice Address - Fax:580-223-5002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH1005-1005314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
37-5379Medicare ID - Type UnspecifiedMEDICARE PROVIDER #