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General NPI Number Information
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NPI Number | 1154628790
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Entity Type | Organization
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Legal Business Name | OAK LAKE, LLC
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Dates
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Enumeration Date | 02/17/2011
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Last Update Date | 01/19/2022
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Provider Practice Location Address
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Address Line | 103 HAR-BER RD
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City | GROVE
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State | OK
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Zip | 74345-0547
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Country | US
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Telephone | 918-786-2276
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Fax | 918-786-4526
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Provider Business Mailing Address
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Address Line | 103 HAR-BER ROAD
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City | GROVE
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State | OK
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Zip | 74345-0547
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Country | US
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Telephone | 918-786-2276
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Fax | 918-786-4526
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Authorized Official
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Title or Position | MANAGER
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Name | CHRIS BROGDON
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Credential |
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Telephone | 770-650-8793
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number |
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License Number State |
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