Healthcare Provider Details

I. General information

NPI: 1104992403
Provider Name (Legal Business Name): SPECIALIZED ALTERNATIVES FOR FAMILIES AND YOUTH OF OKLAHOMA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N MERIDIAN AVE SUITE #280-N
OKLAHOMA CITY OK
73107-6560
US

IV. Provider business mailing address

10100 ELIDA RD
DELPHOS OH
45833-9056
US

V. Phone/Fax

Practice location:
  • Phone: 405-942-5570
  • Fax: 405-942-5603
Mailing address:
  • Phone: 419-695-8010
  • Fax: 419-695-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. MARC BLOOMINGDALE
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential: M.S.
Phone: 817-789-2611