Provider Demographics
NPI:1659445377
Name:BIXBY MANOR, LLC
Entity Type:Organization
Organization Name:BIXBY MANOR, LLC
Other - Org Name:BIXBY MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-366-4492
Mailing Address - Street 1:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-0670
Mailing Address - Country:US
Mailing Address - Phone:918-366-4492
Mailing Address - Fax:918-366-6220
Practice Address - Street 1:76 W RACHEL ST
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008-4908
Practice Address - Country:US
Practice Address - Phone:918-366-4491
Practice Address - Fax:918-366-6220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH7203-7203314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375419Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER