Provider Demographics
NPI:1871892109
Name:CONHOLD OF PONCA, LLC
Entity type:Organization
Organization Name:CONHOLD OF PONCA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:JD
Authorized Official - Phone:918-774-9696
Mailing Address - Street 1:111 EAST CHICKASAW
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-0767
Mailing Address - Country:US
Mailing Address - Phone:918-774-9696
Mailing Address - Fax:918-774-9797
Practice Address - Street 1:2024 TURNER ROAD
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601
Practice Address - Country:US
Practice Address - Phone:580-765-3364
Practice Address - Fax:580-765-3376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKNH3607-3607OtherSTATE LICENSE NUMBER