Basic Information
Provider Information | |||||||||
NPI: | 1386815215 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CLETAS COTTAGE DAY TREATMENT CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 358 | ||||||||
Address2: | 527 WEST THIRD STREET | ||||||||
City: | KONAWA | ||||||||
State: | OK | ||||||||
PostalCode: | 74849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5809253286 | ||||||||
FaxNumber: | 5809253924 | ||||||||
Practice Location | |||||||||
Address1: | 220 SOUTH 5TH ST | ||||||||
Address2: |   | ||||||||
City: | NOBLE | ||||||||
State: | OK | ||||||||
PostalCode: | 73068 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5809253286 | ||||||||
FaxNumber: | 5809253924 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/19/2008 | ||||||||
LastUpdateDate: | 04/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANSON | ||||||||
AuthorizedOfficialFirstName: | CASEY | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5809258804 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CENTRAL OKLAHOMA FAMILY MEDICAL CENTER | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X |   |   | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |   |
No ID Information.