Provider Demographics
NPI:1790884849
Name:MID-DEL GROUP HOME, INC.
Entity Type:Organization
Organization Name:MID-DEL GROUP HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-732-8568
Mailing Address - Street 1:PO BOX 30033
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73140-3033
Mailing Address - Country:US
Mailing Address - Phone:405-732-8568
Mailing Address - Fax:405-732-6615
Practice Address - Street 1:1540 REPUBLIC CIR
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-7971
Practice Address - Country:US
Practice Address - Phone:405-732-8568
Practice Address - Fax:405-732-6615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services