Provider Demographics
NPI:1124326434
Name:CONHOLD OF PONCA LLC
Entity type:Organization
Organization Name:CONHOLD OF PONCA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-774-9696
Mailing Address - Street 1:2024 TURNER ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-2732
Mailing Address - Country:US
Mailing Address - Phone:580-765-3364
Mailing Address - Fax:580-765-3376
Practice Address - Street 1:2024 TURNER ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-2732
Practice Address - Country:US
Practice Address - Phone:580-765-3364
Practice Address - Fax:580-765-3376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-10
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH3607-3607314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375194Medicare Oscar/Certification