Provider Demographics
NPI:1831172857
Name:SKYLINE HEIGHTS OPERATING CO LLC
Entity type:Organization
Organization Name:SKYLINE HEIGHTS OPERATING CO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-255-1810
Mailing Address - Street 1:16 NORCROSS ST
Mailing Address - Street 2:STE 100
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3810
Mailing Address - Country:US
Mailing Address - Phone:770-255-1810
Mailing Address - Fax:770-255-0059
Practice Address - Street 1:6202 E 61ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-2119
Practice Address - Country:US
Practice Address - Phone:918-494-8820
Practice Address - Fax:918-494-8837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH72267226314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375034Medicare ID - Type Unspecified