Provider Demographics
NPI:1285724732
Name:HERITAGE VILLAGE NURSING CENTER LLC
Entity type:Organization
Organization Name:HERITAGE VILLAGE NURSING CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-379-6671
Mailing Address - Street 1:801 HIGHWAY 48 NORTH
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848
Mailing Address - Country:US
Mailing Address - Phone:405-379-6671
Mailing Address - Fax:405-379-6674
Practice Address - Street 1:801 HIGHWAY 48 NORTH
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848
Practice Address - Country:US
Practice Address - Phone:405-379-6671
Practice Address - Fax:405-379-6674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH3205-3205314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100777930AMedicaid
OK200111530AMedicaid