Provider Demographics
NPI:1962503318
Name:COLONIAL PLAZA NURSING HOME INC
Entity Type:Organization
Organization Name:COLONIAL PLAZA NURSING HOME INC
Other - Org Name:LINWOOD VILLAGE NURSING & RETIREMENT APARTMENTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-743-7838
Mailing Address - Street 1:530 S LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-4644
Mailing Address - Country:US
Mailing Address - Phone:918-743-7838
Mailing Address - Fax:
Practice Address - Street 1:530 S LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-4644
Practice Address - Country:US
Practice Address - Phone:918-743-7838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0004362313M00000X
OK375471314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100771500AMedicaid
OK100771500AMedicaid