Basic Information
| Provider Information | |||||||||
| NPI: | 1316955198 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAND LAKE MENTAL HEALTH CENTER, INC. | ||||||||
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| OtherOrganizationName: | GRAND LAKE MEDICAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 W DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | NOWATA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740482601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182731841 | ||||||||
| FaxNumber: | 9182731841 | ||||||||
| Practice Location | |||||||||
| Address1: | 17599 S HIGHWAY 88 | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740170801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182731841 | ||||||||
| FaxNumber: | 9182731843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9182731841 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 100732860C | 05 | OK | MEDICAID |