=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679389829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAND LAKE MENTAL HEALTH CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2024
-----------------------------------------------------
Last Update Date | 12/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1015 W WASHBOURNE ST
-----------------------------------------------------
City | JAY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74346-4205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-308-5513
-----------------------------------------------------
Fax | 918-253-6645
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 W DELAWARE AVE
-----------------------------------------------------
City | NOWATA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74048-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-273-1841
-----------------------------------------------------
Fax | 918-273-1843
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JOSHUA CANTWELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-273-1841
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------