Healthcare Provider Details

I. General information

NPI: 1326375379
Provider Name (Legal Business Name): SUGAR MOUNTAIN RETREAT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2009
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27753 S WELLING RD
WELLING OK
74471-2202
US

IV. Provider business mailing address

27753 S WELLING RD
WELLING OK
74471-2202
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-1010
  • Fax: 918-457-5540
Mailing address:
  • Phone: 918-457-4221
  • Fax: 918-457-5540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number310400000X
License Number StateOK

VIII. Authorized Official

Name: DAVETTA MCINTOSH
Title or Position: CEO
Credential:
Phone: 918-457-4221