Provider Demographics
NPI:1699870329
Name:AZALEA PARK MANOR LLC
Entity type:Organization
Organization Name:AZALEA PARK MANOR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-943-1144
Mailing Address - Street 1:5800 W OKMULGEE ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4552
Mailing Address - Country:US
Mailing Address - Phone:918-683-2914
Mailing Address - Fax:918-683-3167
Practice Address - Street 1:4717 W OKMULGEE ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4657
Practice Address - Country:US
Practice Address - Phone:918-683-2914
Practice Address - Fax:918-683-3167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5106-5106314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100772250AMedicaid
OK100772250AMedicaid