Provider Demographics
NPI:1831464304
Name:PENNINGTON CREEK LIFEHOUSE
Entity Type:Organization
Organization Name:PENNINGTON CREEK LIFEHOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:580-371-3799
Mailing Address - Street 1:801 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-2351
Mailing Address - Country:US
Mailing Address - Phone:580-371-3799
Mailing Address - Fax:580-371-2056
Practice Address - Street 1:801 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-2351
Practice Address - Country:US
Practice Address - Phone:580-371-3799
Practice Address - Fax:580-371-2056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200226970Medicare PIN