# OAK LAKE, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Grand Lake Villa
- **Organization subpart:** No

## Provider details

- **NPI number:** 1154628790
- **Authorized official:** CHRIS BROGDON (MANAGER)
- **Authorized official phone:** (770) 650-8793

## Contact information

- **Practice address:** 103 HAR-BER RD, GROVE, OK 74345-0547
- **Practice address phone:** (918) 786-2276
- **Practice address fax:** (918) 786-4526
- **Mailing address:** 103 HAR-BER ROAD, GROVE, OK 74345-0547
- **Mailing address phone:** (918) 786-2276
- **Mailing address fax:** (918) 786-4526

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | — | — | Yes |

## Other

- **Enumeration date:** 02/17/2011
- **Last updated:** 01/19/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 20059540A | — | OK |