Organization
OAK LAKE, LLC
Active
Other names
Grand Lake Villa
Organization subpart
No
Provider details
NPI number
Authorized official
CHRIS BROGDON (MANAGER)
(770) 650-8793
Entity
Organization
Contact information
Practice address
103 HAR-BER RD, GROVE, OK 74345-0547
(918) 786-2276
(918) 786-4526
Mailing address
103 HAR-BER ROAD, GROVE, OK 74345-0547
(918) 786-2276
(918) 786-4526
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
20059540A
—
OK
Enumeration date
02/17/2011
Last updated
01/19/2022
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