Provider Demographics
NPI:1700114253
Name:HIGH CEDAR RESIDENTIAL CARE
Entity Type:Organization
Organization Name:HIGH CEDAR RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LILLIE
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-447-2532
Mailing Address - Street 1:18601 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:NOBLE
Mailing Address - State:OK
Mailing Address - Zip Code:73068-5915
Mailing Address - Country:US
Mailing Address - Phone:405-447-2532
Mailing Address - Fax:405-447-0878
Practice Address - Street 1:18601 CEDAR LN
Practice Address - Street 2:
Practice Address - City:NOBLE
Practice Address - State:OK
Practice Address - Zip Code:73068-5915
Practice Address - Country:US
Practice Address - Phone:405-447-2532
Practice Address - Fax:405-447-0878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3104A0625X
OKRC1401-14013104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness