Provider Demographics
NPI:1457374332
Name:SERVANT LIVING CENTER - MEDFORD LLC
Entity Type:Organization
Organization Name:SERVANT LIVING CENTER - MEDFORD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:D
Authorized Official - Last Name:PILGRIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-285-8166
Mailing Address - Street 1:129 W 1ST STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003
Mailing Address - Country:US
Mailing Address - Phone:405-285-8166
Mailing Address - Fax:405-285-8177
Practice Address - Street 1:616 S FRONT STREET
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OK
Practice Address - Zip Code:73759
Practice Address - Country:US
Practice Address - Phone:405-395-2105
Practice Address - Fax:405-395-2070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
10077703AMedicare ID - Type Unspecified
375352Medicare ID - Type Unspecified