NPIMap

Organization Active NPI

Eidetik of Weleetka, LLC

  • Intellectual Disabilities Intermediate Care Facility
  • Henryetta, OK
National Provider Identifier
1730309337
Registry record updated Dec 23, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
200001110I Issued in OK
Legal business name
EIDETIK OF WELEETKA, LLC
Practice address
1201 W Trudgeon St
Henryetta, OK 74437-4007
Phone
(918) 650-9393
Fax
(918) 650-0270
NPI assigned
Apr 26, 2007
Organization subpart
Yes
Parent organization
EIDETIK OF WELEETKA, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 23, 2022

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

Authorized official

Name
Laila Beaven
Title
Registered Agent
Phone
(270) 389-1919

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X 200001110I OK Primary

Addresses

Primary practice location

1201 W Trudgeon St
Henryetta, OK 74437-4007

Mailing address

1201 W. Trudgeon St.
Henryetta, OK 74437
Phone (918) 650-9393

Other identifiers 1

IdentifierTypeStateIssuer
200001110IMedicaidOK

Other names 2

  • Cross Place Doing business as
  • The Reach Corporation-name to be changed to Other name

National Provider Directory

National Provider Directory
Tax ID family
Eidetik of Weleetka LLC19 organizations share this tax ID, including this one
Part of
Eidetik of Weleetka LLC

Other organizations with this tax ID 18

Organizations that report the same tax identification number in the National Provider Directory.

View all 18

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1177545600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1671753600000",
    "number": "1730309337",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1201 W. TRUDGEON ST.",
            "city": "HENRYETTA",
            "state": "OK",
            "postal_code": "74437",
            "telephone_number": "918-650-9393",
            "fax_number": "918-650-0270"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1201 W TRUDGEON ST",
            "city": "HENRYETTA",
            "state": "OK",
            "postal_code": "744374007",
            "telephone_number": "918-650-9393",
            "fax_number": "918-650-0270"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EIDETIK OF WELEETKA, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "EIDETIK OF WELEETKA, LLC",
        "enumeration_date": "2007-04-26",
        "last_updated": "2022-12-23",
        "certification_date": "2022-12-23",
        "status": "A",
        "authorized_official_last_name": "BEAVEN",
        "authorized_official_first_name": "LAILA",
        "authorized_official_title_or_position": "REGISTERED AGENT",
        "authorized_official_telephone_number": "270-389-1919"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "OK",
            "license": "200001110I",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200001110I",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Cross Place",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "The Reach Corporation-name to be changed to",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Henryetta, OK

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 23, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.