Provider Demographics
NPI:1164544599
Name:EAGLE RIDGE INSTITUTE
Entity Type:Organization
Organization Name:EAGLE RIDGE INSTITUTE
Other - Org Name:EAGLE RIDGE FAMILY TREATMENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-840-1359
Mailing Address - Street 1:5427 EASY ST
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-6621
Mailing Address - Country:US
Mailing Address - Phone:405-282-4377
Mailing Address - Fax:
Practice Address - Street 1:5427 EASY ST
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-6621
Practice Address - Country:US
Practice Address - Phone:405-282-4377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility