Provider Demographics
NPI:1326393554
Name:PENNINGTON CREEK LIFEHOUSE
Entity Type:Organization
Organization Name:PENNINGTON CREEK LIFEHOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REHABILITATION SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:OREON
Authorized Official - Middle Name:ODELL
Authorized Official - Last Name:LEBLANC
Authorized Official - Suffix:
Authorized Official - Credentials:COUNSELOR
Authorized Official - Phone:918-815-1371
Mailing Address - Street 1:11644 N 103RD EAST AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-4821
Mailing Address - Country:US
Mailing Address - Phone:918-815-1371
Mailing Address - Fax:
Practice Address - Street 1:130 N GREENWOOD AVE STE 200
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-1409
Practice Address - Country:US
Practice Address - Phone:539-664-4621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health