Heavener Manor, LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

NH4001-4001 Issued in OK

Legal business name

HEAVENER MANOR, LLC

Practice address

204 W 1St St
Heavener, OK 74937-2062

Phone

(918) 653-2034

Fax

(918) 653-4518

NPI assigned

Apr 3, 2014

Last updated

Jun 7, 2024By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Bradford Montgomery

Title

Member

Phone

(479) 250-5558

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in OK

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1174941496. Details of each certification follow.

• CCN 375434 Skilled nursing facility · Active · Details

Skilled nursing facility certification: CCN 375434

Legal name

HEAVENER MANOR, LLC

Doing business as

HEAVENER MANOR

Certification status

Active

Provider type (POS)

Nursing home – SNF/NF dual certification

Participating since

Mar 29, 2003

Last certification

Apr 3, 2025

Beds

84

Ownership / control type

Limited Liability Corporation

Most recent change of ownership

Mar 31, 2014

Organization structure

LLCProprietary

Incorporated

May 28, 2013 in OK

Enrollment address

114 W 2ND St
Heavener, OK 74937-2002

Nursing home name

HEAVENER NURSING & REHAB

Affiliated entity

BRADFORD MONTGOMERY

Listed as

Heavener Nursing & RehabCCN 375434 · All quality measures

Overall star rating

1 of 5

Health inspections

1 of 5

Staffing

2 of 5

Quality measures

2 of 5

Type

Medicare and Medicaid

Ownership

For profit - Limited Liability company

Certified

Mar 29, 2003

Medicare certification status

ActiveFrom the Provider of Services file

Certified beds

8471.5 residents per day on average

Chain

Bradford Montgomery11 facilities in the chain

Abuse citation

Cited for abuse (Care Compare abuse icon)

Processed by Care Compare on Aug 1, 2026.

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Amy Wilson, D.O.

  • Internal Medicine Physician
  • Fort Smith, AR
  • NPI 1154776409
  NPD (past)

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

• Amy Wilson, D.O.

  • Internal Medicine Physician
  • Fort Smith, AR
  • NPI 1154776409

  Nursing home

  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1396483200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1717718400000",
    "number": "1174941496",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9 PROFESSIONAL DR",
            "city": "BELLA VISTA",
            "state": "AR",
            "postal_code": "727158462",
            "telephone_number": "479-259-5558"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "204 W 1ST ST",
            "city": "HEAVENER",
            "state": "OK",
            "postal_code": "749372062",
            "telephone_number": "918-653-2034",
            "fax_number": "918-653-4518"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HEAVENER MANOR, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-04-03",
        "last_updated": "2024-06-07",
        "certification_date": "2024-06-07",
        "status": "A",
        "authorized_official_last_name": "MONTGOMERY",
        "authorized_official_first_name": "BRADFORD",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "479-250-5558"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "OK",
            "license": "NH4001-4001",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Joni Lynn Fitzgerald
• Gary E. Youree D,D.S. PC
• Nona Gentry, LPC
• Connie Marie Glasco, LPC
• Haskell Regional Hospital, Inc. (HRH Medical Group, Affordable Healthcare Clinic)
• Heavener Public School (Lea) (LeFlore County Special Education Cooperative)
• Heavener Public Schools
• Jill Christine Hendrix
• Charles Joseph Hitt, DC
• Linda J Hoffman, APRN

• Skilled Nursing Facility in Heavener, OK
• Providers in Heavener, OK by specialty
• Skilled Nursing Facility in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 7, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.