Basic Information
| Provider Information | |||||||||
| NPI: | 1083815856 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINDSOR MANOR ASSISTED LIVING | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WINDSOR MANOR HEALTHCARE, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1380 S DOUGLAS BLVD | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731305215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057370881 | ||||||||
| FaxNumber: | 4057370899 | ||||||||
| Practice Location | |||||||||
| Address1: | 4825 NW 23RD ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731271800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059450010 | ||||||||
| FaxNumber: | 4059476542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCENTIRE | ||||||||
| AuthorizedOfficialFirstName: | S | ||||||||
| AuthorizedOfficialMiddleName: | WENDY | ||||||||
| AuthorizedOfficialTitleorPosition: | CORP BUSINESS MGR | ||||||||
| AuthorizedOfficialTelephone: | 4057370881 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL5516-5516 | OK | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.