Healthcare Provider Details

I. General information

NPI: 1447505151
Provider Name (Legal Business Name): CEDAR RIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 NE 50TH ST
OKLAHOMA CITY OK
73141-9118
US

IV. Provider business mailing address

1250 N AIR DEPOT BLVD APT. 111
MIDWEST CITY OK
73110-3349
US

V. Phone/Fax

Practice location:
  • Phone: 405-605-6111
  • Fax:
Mailing address:
  • Phone: 405-921-7322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number283Q00000X
License Number StateOK

VIII. Authorized Official

Name: MARTHA CHRISTINA PHILLIPS
Title or Position: CASE MANAGER
Credential:
Phone: 405-605-5934