Provider Demographics
NPI:1104841071
Name:LIGHTNING CREEK INVESTMENT GROUP INC
Entity Type:Organization
Organization Name:LIGHTNING CREEK INVESTMENT GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-994-5570
Mailing Address - Street 1:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:NOWATA
Mailing Address - State:OK
Mailing Address - Zip Code:74048
Mailing Address - Country:US
Mailing Address - Phone:918-273-3649
Mailing Address - Fax:
Practice Address - Street 1:1100 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CHEROKEE
Practice Address - State:OK
Practice Address - Zip Code:73728-3832
Practice Address - Country:US
Practice Address - Phone:580-596-2141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH0201-0201314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100772060AMedicaid
OK10077206DMedicaid
OKP37-5475Medicare ID - Type UnspecifiedMEDICARE NUMBER