1669480299 NPI number — GRAND LAKE MENTAL HEALTH CENTER, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669480299 NPI number — GRAND LAKE MENTAL HEALTH CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND LAKE MENTAL HEALTH CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GRAND LAKE MENTAL HEALTH CENTER, INC.-DELAWARE COUNTY
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669480299
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
114 W DELAWARE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOWATA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74048-2601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-786-4434
Provider Business Mailing Address Fax Number:
918-786-4435

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1115 HARBOR RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GROVE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-786-4434
Provider Business Practice Location Address Fax Number:
918-786-4435
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COX
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
Authorized Official Title or Position:
MIS/REIMBURSEMENT COORDINATOR
Authorized Official Telephone Number:
918-273-1841

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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