Provider Demographics
NPI:1639166085
Name:HARMON COUNTY HEALTHCARE TRUST AUTHORITY
Entity Type:Organization
Organization Name:HARMON COUNTY HEALTHCARE TRUST AUTHORITY
Other - Org Name:COLONIAL MANOR II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HOPE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-688-9431
Mailing Address - Street 1:PO BOX 793
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:OK
Mailing Address - Zip Code:73550-0793
Mailing Address - Country:US
Mailing Address - Phone:580-688-9431
Mailing Address - Fax:580-688-2491
Practice Address - Street 1:120 W VERSA ST
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:OK
Practice Address - Zip Code:73550-3046
Practice Address - Country:US
Practice Address - Phone:580-688-9431
Practice Address - Fax:580-688-2491
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HARMON COUNTY HEALTHCARE TRUST AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-30
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH2902-2902313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100772150AMedicaid