Provider Demographics
NPI:1679565709
Name:WOODLAWN LP
Entity type:Organization
Organization Name:WOODLAWN LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:MACHTOLFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-282-2600
Mailing Address - Street 1:PO BOX 977
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-0977
Mailing Address - Country:US
Mailing Address - Phone:405-282-2600
Mailing Address - Fax:405-282-2610
Practice Address - Street 1:405 N 20TH ST
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-2103
Practice Address - Country:US
Practice Address - Phone:405-282-1517
Practice Address - Fax:405-282-9007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH4208315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100771000AMedicaid