Provider Demographics
NPI:1053300269
Name:BEDLAM PROPERTIES, LLC
Entity Type:Organization
Organization Name:BEDLAM PROPERTIES, LLC
Other - Org Name:HILLCREST MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO - ISP
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIETZKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-622-4799
Mailing Address - Street 1:1805 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4610
Mailing Address - Country:US
Mailing Address - Phone:918-622-4799
Mailing Address - Fax:918-622-4798
Practice Address - Street 1:1210 S 6TH ST
Practice Address - Street 2:
Practice Address - City:BLACKWELL
Practice Address - State:OK
Practice Address - Zip Code:74631-4219
Practice Address - Country:US
Practice Address - Phone:580-363-3244
Practice Address - Fax:580-363-2613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH36043604314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100772420AMedicaid
OK000375402001OtherBC/BS PROVIDER ID