Provider Demographics
NPI:1598002966
Name:LAKE DRIVE HEALTH CARE LLC
Entity Type:Organization
Organization Name:LAKE DRIVE HEALTH CARE LLC
Other - Org Name:LAKE DRIVE CARE AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JUDAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BIENSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-812-2550
Mailing Address - Street 1:600 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-5415
Mailing Address - Country:US
Mailing Address - Phone:918-652-8101
Mailing Address - Fax:918-652-0253
Practice Address - Street 1:600 LAKE RD
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437-5415
Practice Address - Country:US
Practice Address - Phone:918-652-8101
Practice Address - Fax:918-652-0253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-05
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5605315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100779100AMedicaid