1942840889 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 1942840889 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 MENTAL HEALTH
Provider Other Organization Name Type Code:
3
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:
1942840889
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2022
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:
918-273-1841
Provider Business Mailing Address Fax Number:
918-273-1843

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 S TREATY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74354-5327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-540-1511
Provider Business Practice Location Address Fax Number:
918-542-7374
Provider Enumeration Date:
01/08/2020

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
918-273-1841

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com