Provider Demographics
NPI:1467460931
Name:GRAND LAKE MENTAL HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:GRAND LAKE MENTAL HEALTH CENTER, INC.
Other - Org Name:GRAND MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-273-1841
Mailing Address - Street 1:114 W DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:NOWATA
Mailing Address - State:OK
Mailing Address - Zip Code:74048-2601
Mailing Address - Country:US
Mailing Address - Phone:918-273-1841
Mailing Address - Fax:918-273-1289
Practice Address - Street 1:114 W DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:NOWATA
Practice Address - State:OK
Practice Address - Zip Code:74048-2601
Practice Address - Country:US
Practice Address - Phone:918-273-1841
Practice Address - Fax:918-273-1289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100732860NMedicaid