Provider Demographics
NPI:1326202003
Name:EAGLE RIDGE
Entity Type:Organization
Organization Name:EAGLE RIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERSONNEL & COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-858-2821
Mailing Address - Street 1:PO BOX 1182
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-1182
Mailing Address - Country:US
Mailing Address - Phone:405-282-8232
Mailing Address - Fax:405-282-3305
Practice Address - Street 1:1916 E PERKINS AVE
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-5804
Practice Address - Country:US
Practice Address - Phone:405-282-8262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness