Provider Demographics
NPI:1790197747
Name:ARBOR VILLAGE NURSING, LLC
Entity Type:Organization
Organization Name:ARBOR VILLAGE NURSING, LLC
Other - Org Name:NORTHSIDE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:PILGRIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-285-8166
Mailing Address - Street 1:102 E LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-2858
Mailing Address - Country:US
Mailing Address - Phone:918-224-0833
Mailing Address - Fax:
Practice Address - Street 1:3325 FRENCH PARK DR
Practice Address - Street 2:SUITE 6
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-7277
Practice Address - Country:US
Practice Address - Phone:405-285-8166
Practice Address - Fax:405-563-9447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-27
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH1902314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375523Medicare Oscar/Certification