Provider Demographics
NPI:1619297421
Name:EUFAULA LAKE FAMILY DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:EUFAULA LAKE FAMILY DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-452-3133
Mailing Address - Street 1:RT 1 BOX 131-C
Mailing Address - Street 2:
Mailing Address - City:EAUFAULA
Mailing Address - State:OK
Mailing Address - Zip Code:74432
Mailing Address - Country:US
Mailing Address - Phone:918-452-3133
Mailing Address - Fax:
Practice Address - Street 1:RT 1 BOX 131-C
Practice Address - Street 2:
Practice Address - City:EAUFAULA
Practice Address - State:OK
Practice Address - Zip Code:74432
Practice Address - Country:US
Practice Address - Phone:918-452-3133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21330251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management