Provider Demographics
NPI:1245571165
Name:HEARTSWORTH SENIOR LIVING, LLC
Entity type:Organization
Organization Name:HEARTSWORTH SENIOR LIVING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
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:PO BOX 990
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-0990
Mailing Address - Country:US
Mailing Address - Phone:405-285-8166
Mailing Address - Fax:
Practice Address - Street 1:1200 W CANADIAN AVE
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-2702
Practice Address - Country:US
Practice Address - Phone:918-256-8768
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH1802--1802314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375493Medicare Oscar/Certification