Provider Demographics
NPI:1689745291
Name:CEDAR CREST MANOR INC
Entity Type:Organization
Organization Name:CEDAR CREST MANOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARRI
Authorized Official - Middle Name:
Authorized Official - Last Name:ALDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-355-1616
Mailing Address - Street 1:1700 NW FORT SILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-4064
Mailing Address - Country:US
Mailing Address - Phone:580-355-1616
Mailing Address - Fax:580-355-2814
Practice Address - Street 1:1700 NW FORT SILL BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-4064
Practice Address - Country:US
Practice Address - Phone:580-355-1616
Practice Address - Fax:580-355-2814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH1602-1602313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100773120AMedicaid
OK37E548OtherFEDERAL ID NUMBER