Provider Demographics
NPI:1588179600
Name:OKLAHOMA HOMES FOR THE DEVELOPMENTALLY DISABLED, LLC
Entity Type:Organization
Organization Name:OKLAHOMA HOMES FOR THE DEVELOPMENTALLY DISABLED, LLC
Other - Org Name:MATTOX HALL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRUITS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-725-3400
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74630-0366
Mailing Address - Country:US
Mailing Address - Phone:580-725-3400
Mailing Address - Fax:
Practice Address - Street 1:209 E GARBER RD
Practice Address - Street 2:
Practice Address - City:GARBER
Practice Address - State:OK
Practice Address - Zip Code:73738-1039
Practice Address - Country:US
Practice Address - Phone:580-863-2200
Practice Address - Fax:580-863-2206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-12
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH2403-2403315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities