Oak Lake, LLC
Organization Active NPI Skilled Nursing Facility · Grove, OK
NPI 1154628790 · NPPES record last updated Jan 19, 2022
Key facts
- NPI
- 1154628790
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Skilled Nursing Facility 314000000X
- Legal business name
- OAK LAKE, LLC
- Practice address
- 103 Har-Ber Rd
Grove, OK 74345-0547 - Phone
- (918) 786-2276
- Fax
- (918) 786-4526
- NPI assigned
- Feb 17, 2011
- Organization subpart
- No
Authorized official
- Name
- Chris Brogdon
- Title
- Manager
- Phone
- (770) 650-8793
Owners & managing parties with NPI records 1
Facilities with the same owner 8
Practitioners 4
-
Arvid Lade, M.D.
-
Hieu CHI Nguyen, M.D.
-
Kyle J Schauf, MD
Affiliated clinicians 2
-
Kyle J Schauf, MD
Medicare Care Compare: Nursing home
- Listed as
- Grand Lake Villa
- 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
- Active
- Certified beds
- 100 · 65.9 residents per day on average
- Chain
- Marsh Pointe Management
- Abuse citation
- Cited for abuse (Care Compare abuse icon)
- Penalties (3 years)
- 1 · fines totaling $32,576
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 37D0857570 | Grand Lake Villa | Certificate of waiver | Aug 31, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in OK
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
- LLC · Proprietary
- 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
All disclosed owners & managing parties 10
| Name | Role | Since | Share |
|---|---|---|---|
| Connie Brogdon |
5% Or Greater Indirect Ownership Interest | Jul 30, 2020 | 64.99% |
| Adp of the SNF | Jul 30, 2020 | ||
| |
Adp of the SNF | Apr 1, 2024 | |
| Cheryl Nichols |
Corporate Officer |
Apr 6, 2016 | |
| Operational/Managerial Control | Mar 20, 2024 | ||
| Adp of the SNF | Apr 6, 2016 | ||
| Oklahoma Operating LLC |
5% Or Greater Direct Ownership Interest | Jul 30, 2020 | 65% |
| Adp of the SNF | Jul 30, 2020 | ||
| Oklahoma Financial LLC |
5% Or Greater Direct Ownership Interest | Jul 30, 2020 | 35% |
| Adp of the SNF | Jul 30, 2020 | ||
| |
Adp of the SNF | Jul 30, 2020 | |
| Indirect Ownership Interest | Jul 30, 2020 | 0.01% | |
| Marsh Pointe Management LLC |
Operational/Managerial Control | Mar 1, 2014 | 100% |
| Adp of the SNF | May 20, 2025 | ||
| |
Adp of the SNF | May 20, 2025 | |
| Christopher F Brogdon |
Corporate Officer |
Jul 29, 2011 | |
| Operational/Managerial Control |
Jul 29, 2011 | 100% | |
| Managing Control - Governing Body |
Jul 29, 2011 | ||
| Adp of the SNF | Jul 29, 2011 | ||
| Richard H Tidwell |
Operational/Managerial Control | Aug 9, 2018 | |
| Adp of the SNF | Aug 9, 2018 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20110824000697 | OK | Part a Provider - Skilled Nursing Facility | 8527238864 | Practice locations: Grove, OK |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Skilled Nursing Facility | 314000000X | Yes |
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 identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 20059540A | Medicaid | OK |
Other names
- Grand Lake Villa
Other providers in Grove, OK
- Paige Nitz
- Evan L North
- Northeast Oklahoma Family Practice & Obstetrics
- Tiffanie Nutt
- Tayler M O'Field
- Dulce Ochoa
- Justin Ogletree
- Douglas Allen Ohlstrom
- Oklahoma Cataract and Laser Center
- Osu Center for Health Sciences
All providers in Grove, OK · Skilled Nursing Facility in Oklahoma
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 19, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.