Provider Demographics
NPI:1427046796
Name:HENNESSEY MANOR NURSING HOME INC
Entity type:Organization
Organization Name:HENNESSEY MANOR NURSING HOME INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE/MEDICARE
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:PITA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-622-6300
Mailing Address - Street 1:705 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:HENNESSEY
Mailing Address - State:OK
Mailing Address - Zip Code:73742-1620
Mailing Address - Country:US
Mailing Address - Phone:405-853-6027
Mailing Address - Fax:405-853-4389
Practice Address - Street 1:705 E 3RD ST
Practice Address - Street 2:
Practice Address - City:HENNESSEY
Practice Address - State:OK
Practice Address - Zip Code:73742-1620
Practice Address - Country:US
Practice Address - Phone:405-853-6027
Practice Address - Fax:405-853-4389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH3703-3703313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731473404001OtherBLUE CROSS BLUE SHIELD OK
OK200059260AMedicaid
OK37-5485Medicare ID - Type UnspecifiedMEDICARE OKLAHOMA