Provider Demographics
NPI:1841600863
Name:GRAND LAKE MENTAL HEALTH CENTER INC.
Entity Type:Organization
Organization Name:GRAND LAKE MENTAL HEALTH CENTER INC.
Other - Org Name:GRAND LAKE MEDICAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-273-1841
Mailing Address - Street 1:114 W DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:NOWATA
Mailing Address - State:OK
Mailing Address - Zip Code:74048-2601
Mailing Address - Country:US
Mailing Address - Phone:918-273-1841
Mailing Address - Fax:918-273-1843
Practice Address - Street 1:138 S MAIN
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:OK
Practice Address - Zip Code:74331-1822
Practice Address - Country:US
Practice Address - Phone:918-257-4244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-29
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)