Provider Demographics
NPI:1821093352
Name:PSG - WILLOW PARK LLC
Entity Type:Organization
Organization Name:PSG - WILLOW PARK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:HANKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-536-1279
Mailing Address - Street 1:7019 NW CACHE RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-2707
Mailing Address - Country:US
Mailing Address - Phone:580-536-1279
Mailing Address - Fax:580-510-0017
Practice Address - Street 1:7019 NW CACHE RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-2707
Practice Address - Country:US
Practice Address - Phone:580-536-1279
Practice Address - Fax:580-510-0017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH1607-1607313M00000X
OKNH 16071607314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375431Medicare ID - Type Unspecified