Provider Demographics
NPI:1154628790
Name:OAK LAKE, LLC
Entity Type:Organization
Organization Name:OAK LAKE, LLC
Other - Org Name:GRAND LAKE VILLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-650-8793
Mailing Address - Street 1:103 HAR-BER ROAD
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74345-0547
Mailing Address - Country:US
Mailing Address - Phone:918-786-2276
Mailing Address - Fax:918-786-4526
Practice Address - Street 1:103 HAR-BER RD
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74345-0547
Practice Address - Country:US
Practice Address - Phone:918-786-2276
Practice Address - Fax:918-786-4526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20059540AMedicaid
OK20059540AMedicaid