Provider Demographics
NPI:1568682169
Name:EIDETIK OF WELEETKA, LLC
Entity Type:Organization
Organization Name:EIDETIK OF WELEETKA, LLC
Other - Org Name:THE REACH CORPORATION COUNTRY PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:LAILA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BEAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-389-1919
Mailing Address - Street 1:1201 W TRUDGEON ST
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-4007
Mailing Address - Country:US
Mailing Address - Phone:918-650-9393
Mailing Address - Fax:918-650-0270
Practice Address - Street 1:1201 W TRUDGEON ST
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437-4007
Practice Address - Country:US
Practice Address - Phone:918-650-9393
Practice Address - Fax:918-650-0270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK100769710A315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100769710AMedicaid