Provider Demographics
NPI:1972762235
Name:LOOSEN CENTER
Entity Type:Organization
Organization Name:LOOSEN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:OBRIEN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:405-263-4658
Mailing Address - Street 1:PO BOX 245
Mailing Address - Street 2:
Mailing Address - City:OKARCHE
Mailing Address - State:OK
Mailing Address - Zip Code:73762-0245
Mailing Address - Country:US
Mailing Address - Phone:405-263-4658
Mailing Address - Fax:
Practice Address - Street 1:6TH AND TEXAS
Practice Address - Street 2:
Practice Address - City:OKARCHE
Practice Address - State:OK
Practice Address - Zip Code:73762-0245
Practice Address - Country:US
Practice Address - Phone:405-263-4658
Practice Address - Fax:405-263-4718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK315P00000X315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100771890AMedicaid