Provider Demographics
NPI:1619459708
Name:GRAND LAKE HEALTH CARE, LLC
Entity Type:Organization
Organization Name:GRAND LAKE HEALTH CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GELINAS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:918-787-3491
Mailing Address - Street 1:62500 E 247 LOOP
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-7435
Mailing Address - Country:US
Mailing Address - Phone:918-787-5240
Mailing Address - Fax:
Practice Address - Street 1:601 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-3429
Practice Address - Country:US
Practice Address - Phone:918-801-6085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-05
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK80573363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20313460AMedicaid