Provider Demographics
NPI:1912025982
Name:SERVANT LIVING CENTER - BEGGS, LLC
Entity Type:Organization
Organization Name:SERVANT LIVING CENTER - BEGGS, LLC
Other - Org Name:COUNTRY LANE COTTAGE #4
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING 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:P.O. BOX 990
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083
Mailing Address - Country:US
Mailing Address - Phone:405-285-8166
Mailing Address - Fax:405-285-8177
Practice Address - Street 1:304 E 7TH ST
Practice Address - Street 2:
Practice Address - City:BEGGS
Practice Address - State:OK
Practice Address - Zip Code:74421
Practice Address - Country:US
Practice Address - Phone:918-267-3362
Practice Address - Fax:918-267-3344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5618315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200054610EMedicaid