Provider Demographics
NPI:1821119447
Name:EAGLE RIDGE INSTITUTE
Entity Type:Organization
Organization Name:EAGLE RIDGE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WELLMEIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-458-3554
Mailing Address - Street 1:109 S HARRILL AVE
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-5317
Mailing Address - Country:US
Mailing Address - Phone:918-485-3554
Mailing Address - Fax:
Practice Address - Street 1:109 S HARRILL AVE
Practice Address - Street 2:1
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-5317
Practice Address - Country:US
Practice Address - Phone:918-485-3554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health