Healthcare Provider Details

I. General information

NPI: 1538299417
Provider Name (Legal Business Name): SUGAR MOUNTAIN RETREAT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26403 S 581 RD
WELLING OK
74471-2303
US

IV. Provider business mailing address

26403 S 581 RD
WELLING OK
74471-2303
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberRC 0201-0201
License Number StateOK

VIII. Authorized Official

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