Healthcare Provider Details

I. General information

NPI: 1174730758
Provider Name (Legal Business Name): HIGH CEDAR RES. CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18601 CEDAR LN
NOBLE OK
73068-5915
US

IV. Provider business mailing address

18601 CEDAR LN
NOBLE OK
73068-5915
US

V. Phone/Fax

Practice location:
  • Phone: 405-447-2532
  • Fax:
Mailing address:
  • Phone: 405-447-2532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberRC1404-1404
License Number StateOK

VIII. Authorized Official

Name: MRS. LILLIE FAYE HENDERSON
Title or Position: ADMINISTRATOR OWNER
Credential:
Phone: 405-447-2532