Organization
BEDLAM PROPERTIES, LLC
Active
Other names
Hillcrest Manor
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MARK A LIETZKE (CEO - ISP)
(918) 622-4799
Entity
Organization
Contact information
Practice address
1210 S 6TH ST, BLACKWELL, OK 74631-4219
(580) 363-3244
(580) 363-2613
Mailing address
1805 E 15TH ST, TULSA, OK 74104-4610
(918) 622-4799
(918) 622-4798
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
NH36043604
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000375402001
BC/BS PROVIDER ID
OK
05
—
100772420A
—
OK
Enumeration date
10/19/2005
Last updated
08/26/2021
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