NPIMap

Organization Active NPI

Oak Lake, LLC

Doing business as Grand Lake Villa

  • Skilled Nursing Facility
  • Grove, OK
National Provider Identifier
1154628790
Registry record updated Jan 19, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
OAK LAKE, LLC
Doing business as
Grand Lake Villa
Practice address
103 Har-Ber Rd
Grove, OK 74345-0547
Phone
(918) 786-2276
Fax
(918) 786-4526
NPI assigned
Feb 17, 2011
Last updated
Jan 19, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 19, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Chris Brogdon
Title
Manager
Phone
(770) 650-8793

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X Primary

Addresses

Primary practice location

103 Har-Ber Rd
Grove, OK 74345-0547

Mailing address

103 Har-Ber Road
Grove, OK 74345-0547
Phone (918) 786-2276

Other names 1

  • Grand Lake Villa Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OK

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110824000697 OK Part A Provider - Skilled Nursing Facility 8527238864 Practice locations: Grove, OK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1154628790. Details of each certification follow.

Skilled nursing facility certification: CCN 375116

Legal name
OAK LAKE, LLC
Doing business as
GRAND LAKE VILLA
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Jan 7, 1992
Last certification
Jun 12, 2024
Beds
100
Ownership / control type
Limited Liability Corporation
Organization structure
LLCProprietary
Incorporated
Mar 2, 2010 in GA
Enrollment address
103 Har-Ber Rd
Grand Lake Villa
Grove, OK 74344
Nursing home name
GRAND LAKE VILLA
Affiliated entity
MARSH POINTE MANAGEMENT

Care Compare: Nursing home

Medicare Care Compare
Listed as
Grand Lake VillaCCN 375116 · All quality measures
Overall star rating
2 of 5
Health inspections
1 of 5
Staffing
5 of 5
Quality measures
5 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
Jan 7, 1992
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
10065.9 residents per day on average
Chain
Marsh Pointe Management6 facilities in the chain
Abuse citation
Cited for abuse (Care Compare abuse icon)
Penalties (3 years)
1Fines totaling $32,576

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
37D0857570Grand Lake Villa103 Har-Ber Rd, Grove, OK 74345Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory

Locations

2485 N Main St
Ste 2201
Jay, OK 74346

Ownership & related parties

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Connie Brogdon Individual 5% Or Greater Indirect Ownership Interest Jul 30, 2020 64.99%
Adp of the SNF Jul 30, 2020
Individual Adp of the SNF Apr 1, 2024
Cheryl Nichols Individual Corporate OfficerDirector of Operations Apr 6, 2016
Operational/Managerial Control Mar 20, 2024
Adp of the SNF Apr 6, 2016
Oklahoma Operating LLC Organization, Atlanta, GA LLC, For-profit, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jul 30, 2020 65%
Adp of the SNF Jul 30, 2020
Oklahoma Financial LLC Organization, Eatontown, NJ LLC, For-profit, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jul 30, 2020 35%
Adp of the SNF Jul 30, 2020
Individual Adp of the SNF Jul 30, 2020
Indirect Ownership Interest Jul 30, 2020 0.01%
Marsh Pointe Management LLC Organization, Atlanta, GA LLC, Management services company, For-profit, Chain home office Operational/Managerial Control Mar 1, 2014 100%
Adp of the SNF May 20, 2025
Organization, Portland, OR LLC, Consulting firm, For-profit Adp of the SNF May 20, 2025
Christopher F Brogdon Individual Corporate OfficerManager Jul 29, 2011
Operational/Managerial ControlManager Jul 29, 2011 100%
Managing Control - Governing BodyManager Jul 29, 2011
Adp of the SNF Jul 29, 2011
Richard H Tidwell Individual Operational/Managerial Control Aug 9, 2018
Adp of the SNF Aug 9, 2018

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 8

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1297900800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1642550400000",
    "number": "1154628790",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "103 HAR-BER ROAD",
            "city": "GROVE",
            "state": "OK",
            "postal_code": "743450547",
            "telephone_number": "918-786-2276",
            "fax_number": "918-786-4526"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "103 HAR-BER RD",
            "city": "GROVE",
            "state": "OK",
            "postal_code": "743450547",
            "telephone_number": "918-786-2276",
            "fax_number": "918-786-4526"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OAK LAKE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-02-17",
        "last_updated": "2022-01-19",
        "certification_date": "2022-01-19",
        "status": "A",
        "authorized_official_last_name": "BROGDON",
        "authorized_official_first_name": "CHRIS",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "770-650-8793"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Grand Lake Villa",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Grand Lake Villa",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grove, OK

Sources for this page

Verify at the official NPI Registry.