Provider Demographics
NPI:1881880847
Name:CCPC, LLC
Entity type:Organization
Organization Name:CCPC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-865-7701
Mailing Address - Street 1:521 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-5109
Mailing Address - Country:US
Mailing Address - Phone:479-410-1740
Mailing Address - Fax:479-410-1596
Practice Address - Street 1:404 EAST CIMARRON
Practice Address - Street 2:
Practice Address - City:MANNFORD
Practice Address - State:OK
Practice Address - Zip Code:74044-1300
Practice Address - Country:US
Practice Address - Phone:918-865-7701
Practice Address - Fax:918-865-7792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375346Medicare Oscar/Certification