Provider Demographics
NPI:1164684957
Name:MEADOW BROOK ICF/MR #2
Entity Type:Organization
Organization Name:MEADOW BROOK ICF/MR #2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-658-3656
Mailing Address - Street 1:1500 MEADOW LANE
Mailing Address - Street 2:
Mailing Address - City:HOWE
Mailing Address - State:OK
Mailing Address - Zip Code:74940
Mailing Address - Country:US
Mailing Address - Phone:918-658-3656
Mailing Address - Fax:918-658-3967
Practice Address - Street 1:1500 MEADOW LANE
Practice Address - Street 2:
Practice Address - City:HOWE
Practice Address - State:OK
Practice Address - Zip Code:74940
Practice Address - Country:US
Practice Address - Phone:918-658-3656
Practice Address - Fax:918-658-3967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH4004-4004310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKNH4004-4004OtherOKLAHOMA STATE DEPARTMENT OF HEALTH