Provider Demographics
NPI:1386815215
Name:CLETAS COTTAGE DAY TREATMENT CENTER
Entity Type:Organization
Organization Name:CLETAS COTTAGE DAY TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:H
Authorized Official - Last Name:ANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-925-8804
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:527 WEST THIRD STREET
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849
Mailing Address - Country:US
Mailing Address - Phone:580-925-3286
Mailing Address - Fax:580-925-3924
Practice Address - Street 1:220 SOUTH 5TH ST
Practice Address - Street 2:
Practice Address - City:NOBLE
Practice Address - State:OK
Practice Address - Zip Code:73068
Practice Address - Country:US
Practice Address - Phone:580-925-3286
Practice Address - Fax:580-925-3924
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL OKLAHOMA FAMILY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========Medicare PIN
OK371804Medicare PIN