Organization
EIDETIK OF WELEETKA, LLC
Active
Other names
The Reach Corporation Country Place
Organization subpart
No
Provider details
NPI number
Authorized official
LAILA M BEAVEN (REGISTERED AGENT)
(270) 389-1919
Entity
Organization
Contact information
Practice address
1201 W TRUDGEON ST, HENRYETTA, OK 74437-4007
(918) 650-9393
(918) 650-0270
Mailing address
1201 W TRUDGEON ST, HENRYETTA, OK 74437-4007
(918) 650-9393
(918) 650-0270
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
100769710A
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100769710A
—
OK
Enumeration date
04/26/2007
Last updated
01/27/2023
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