Healthcare Provider Details

I. General information

NPI: 1851346142
Provider Name (Legal Business Name): PEAK MEDICAL OKLAHOMA NO. 12, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 LAKE RD
HENRYETTA OK
74437-5415
US

IV. Provider business mailing address

101 SUN AVE NE COMPLIANCE DEPARTMENT
ALBUQUERQUE NM
87109-4373
US

V. Phone/Fax

Practice location:
  • Phone: 918-652-8101
  • Fax: 918-652-8209
Mailing address:
  • Phone: 505-821-3355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License NumberNH56055605
License Number StateOK

VIII. Authorized Official

Name: WILLIAM A. MATHIES
Title or Position: PRESIDENT DIRECTOR
Credential:
Phone: 505-821-3355