Provider Demographics
NPI:1073994596
Name:ABRIGHTERLIGHTRESDIENTIAL CARE HOME LLC
Entity Type:Organization
Organization Name:ABRIGHTERLIGHTRESDIENTIAL CARE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BIRGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-378-5686
Mailing Address - Street 1:2708 S HEMLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-0817
Mailing Address - Country:US
Mailing Address - Phone:918-378-5686
Mailing Address - Fax:918-286-1404
Practice Address - Street 1:2708 S HEMLOCK AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-0817
Practice Address - Country:US
Practice Address - Phone:918-378-5686
Practice Address - Fax:918-286-1404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRC7276320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities