Peak Medical Oklahoma No. 12, Inc.

Primary specialty

Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X

License

NH56055605 Issued in OK

Legal business name

PEAK MEDICAL OKLAHOMA NO. 12, INC.

Practice address

600 Lake Rd
Henryetta, OK 74437-5415

Phone

(918) 652-8101

Fax

(918) 652-8209

NPI assigned

May 24, 2006

Organization subpart

Yes

Parent organization

SUNBRIDGE HEALTHCARE CORPORATIONAs reported in NPPES

Name

William A. Mathies

Title

President Director

Phone

(505) 821-3355

Part of

Terrace Hghts Nursing H

• Lake Drive Home Doing business as

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Sep 28, 2009.

{
    "created_epoch": "1148428800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1254096000000",
    "number": "1851346142",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "101 SUN AVE NE",
            "address_2": "COMPLIANCE DEPARTMENT",
            "city": "ALBUQUERQUE",
            "state": "NM",
            "postal_code": "871094373",
            "telephone_number": "505-821-3355"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "600 LAKE RD",
            "city": "HENRYETTA",
            "state": "OK",
            "postal_code": "744375415",
            "telephone_number": "918-652-8101",
            "fax_number": "918-652-8209"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEAK MEDICAL OKLAHOMA NO. 12, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SUNBRIDGE HEALTHCARE CORPORATION",
        "enumeration_date": "2006-05-24",
        "last_updated": "2009-09-28",
        "status": "A",
        "authorized_official_last_name": "MATHIES",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_middle_name": "A.",
        "authorized_official_title_or_position": "PRESIDENT DIRECTOR",
        "authorized_official_telephone_number": "505-821-3355"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "OK",
            "license": "NH56055605",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100779100A",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Drive Home",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• All providers in Henryetta, OK
• Intellectual Disabilities Intermediate Care Facility in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 28, 2009; 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.