Healthcare Provider Details

I. General information

NPI: 1932286119
Provider Name (Legal Business Name): LIBERTY OF OKLAHOMA CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2616 NORTH 30TH STREET
ENID OK
73701-8760
US

IV. Provider business mailing address

2616 NORTH 30TH STREET
ENID OK
73701-8760
US

V. Phone/Fax

Practice location:
  • Phone: 580-548-2699
  • Fax: 580-213-2799
Mailing address:
  • Phone: 580-548-2699
  • Fax: 580-213-2799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License NumberNH24142414
License Number StateOK

VIII. Authorized Official

Name: HUGH M. SAGE
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 580-213-2782