Provider Demographics
NPI:1033586664
Name:COLONIAL PARK MANOR, LLC
Entity type:Organization
Organization Name:COLONIAL PARK MANOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:405-380-6671
Mailing Address - Street 1:600 W FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:OKEMAH
Mailing Address - State:OK
Mailing Address - Zip Code:74859-6442
Mailing Address - Country:US
Mailing Address - Phone:918-623-1936
Mailing Address - Fax:918-623-2287
Practice Address - Street 1:600 W. FRONTAGE ROAD
Practice Address - Street 2:
Practice Address - City:OKEMAH
Practice Address - State:OK
Practice Address - Zip Code:74859-6433
Practice Address - Country:US
Practice Address - Phone:918-623-1936
Practice Address - Fax:918-623-1936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-31
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5405-5405314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200649070AMedicaid