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General NPI Number Information
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NPI Number | 1326375379
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Entity Type | Organization
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Legal Business Name | SUGAR MOUNTAIN RETREAT, INC.
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Dates
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Enumeration Date | 11/12/2009
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Last Update Date | 11/12/2009
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Provider Practice Location Address
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Address Line | 27753 S WELLING RD
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City | WELLING
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State | OK
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Zip | 74471-2202
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Country | US
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Telephone | 918-456-1010
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Fax | 918-457-5540
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Provider Business Mailing Address
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Address Line | 27753 S WELLING RD
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City | WELLING
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State | OK
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Zip | 74471-2202
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Country | US
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Telephone | 918-457-4221
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Fax | 918-457-5540
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Authorized Official
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Title or Position | CEO
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Name | DAVETTA MCINTOSH
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Credential |
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Telephone | 918-457-4221
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 310400000X
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License Number State | OK
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