Healthcare Provider Details

I. General information

NPI: 1316955198
Provider Name (Legal Business Name): GRAND LAKE MENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17599 S HIGHWAY 88
CLAREMORE OK
74017-0801
US

IV. Provider business mailing address

114 W DELAWARE AVE
NOWATA OK
74048-2601
US

V. Phone/Fax

Practice location:
  • Phone: 918-273-1841
  • Fax: 918-273-1843
Mailing address:
  • Phone: 918-273-1841
  • Fax: 918-273-1841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LARRY SMITH
Title or Position: CEO
Credential:
Phone: 918-273-1841