Organization
PEAK MEDICAL OKLAHOMA NO. 12, INC.
Active
Parent organization
SUNBRIDGE HEALTHCARE CORPORATION
Other names
Lake Drive Home
Organization subpart
Yes
Provider details
NPI number
Legal business name
SUNBRIDGE HEALTHCARE CORPORATION
Authorized official
WILLIAM A. MATHIES (PRESIDENT DIRECTOR)
(505) 821-3355
Entity
Organization
Contact information
Practice address
600 LAKE RD, HENRYETTA, OK 74437-5415
(918) 652-8101
(918) 652-8209
Mailing address
101 SUN AVE NE, COMPLIANCE DEPARTMENT, ALBUQUERQUE, NM 87109-4373
(505) 821-3355
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
NH56055605
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100779100A
—
OK
Enumeration date
05/24/2006
Last updated
09/28/2009
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