Provider Demographics
NPI:1952758294
Name:OK4 BROADWAY OPCO LLC
Entity Type:Organization
Organization Name:OK4 BROADWAY OPCO LLC
Other - Org Name:BROADWAY MANOR NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-724-8950
Mailing Address - Street 1:1622 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-4601
Mailing Address - Country:US
Mailing Address - Phone:918-683-2851
Mailing Address - Fax:
Practice Address - Street 1:1622 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-4601
Practice Address - Country:US
Practice Address - Phone:918-683-2851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPENDINGMedicare Oscar/Certification