Provider Demographics
NPI:1558025916
Name:OKLAHOMA HOMES FOR THE DEVELOPMENTALLY DISABLED, LLC
Entity Type:Organization
Organization Name:OKLAHOMA HOMES FOR THE DEVELOPMENTALLY DISABLED, LLC
Other - Org Name:BARRY'S BUNKHOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CONSUELA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLEZAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-725-3533
Mailing Address - Street 1:4621 SPRING RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-6006
Mailing Address - Country:US
Mailing Address - Phone:580-234-8200
Mailing Address - Fax:580-234-5078
Practice Address - Street 1:4621 SPRING RIDGE RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-6006
Practice Address - Country:US
Practice Address - Phone:580-234-8200
Practice Address - Fax:580-234-5078
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OKLAHOMA HOMES FOR THE DEVELOPMENTALLY DISABLED, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities