Provider Demographics
NPI:1932286119
Name:LIBERTY OF OKLAHOMA CORPORATION
Entity Type:Organization
Organization Name:LIBERTY OF OKLAHOMA CORPORATION
Other - Org Name:ROBERT M. GREER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HUGH
Authorized Official - Middle Name:M
Authorized Official - Last Name:SAGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:580-213-2782
Mailing Address - Street 1:2616 NORTH 30TH STREET
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-8760
Mailing Address - Country:US
Mailing Address - Phone:580-548-2699
Mailing Address - Fax:580-213-2799
Practice Address - Street 1:2616 NORTH 30TH STREET
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-8760
Practice Address - Country:US
Practice Address - Phone:580-548-2699
Practice Address - Fax:580-213-2799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310500000X
OKNH24142414315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100769310AMedicaid