Provider Demographics
NPI:1336132539
Name:SENIOR VILLAGE NURSING HOME
Entity type:Organization
Organization Name:SENIOR VILLAGE NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:405-360-2562
Mailing Address - Street 1:1104 N MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:BLANCHARD
Mailing Address - State:OK
Mailing Address - Zip Code:73010-6504
Mailing Address - Country:US
Mailing Address - Phone:405-485-3315
Mailing Address - Fax:
Practice Address - Street 1:1104 N MADISON AVE
Practice Address - Street 2:
Practice Address - City:BLANCHARD
Practice Address - State:OK
Practice Address - Zip Code:73010-6504
Practice Address - Country:US
Practice Address - Phone:405-485-3315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH4403-4403313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility