Provider Demographics
NPI:1265507933
Name:DUNGARVIN OKLAHOMA LLC
Entity Type:Organization
Organization Name:DUNGARVIN OKLAHOMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:KRESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-699-0206
Mailing Address - Street 1:1444 NORTHLAND DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1032
Mailing Address - Country:US
Mailing Address - Phone:651-699-0206
Mailing Address - Fax:651-699-0799
Practice Address - Street 1:9210 S WESTERN AVE STE A-22
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-4982
Practice Address - Country:US
Practice Address - Phone:405-759-2611
Practice Address - Fax:405-759-2650
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DUNGARVIN GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-21
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK100631340E320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100631340EOtherOHCA PROVIDER ID