Basic Information
Provider Information | |||||||||
NPI: | 1104992403 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPECIALIZED ALTERNATIVES FOR FAMILIES AND YOUTH OF OKLAHOMA, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAFY OF OKLAHOMA - OKLAHOMA CITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10100 ELIDA RD | ||||||||
Address2: |   | ||||||||
City: | DELPHOS | ||||||||
State: | OH | ||||||||
PostalCode: | 458339056 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4196958010 | ||||||||
FaxNumber: | 4196950004 | ||||||||
Practice Location | |||||||||
Address1: | 300 N MERIDIAN AVE | ||||||||
Address2: | SUITE #280-N | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731076560 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4059425570 | ||||||||
FaxNumber: | 4059425603 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2006 | ||||||||
LastUpdateDate: | 02/07/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLOOMINGDALE | ||||||||
AuthorizedOfficialFirstName: | MARC | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 8177892611 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.S. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 322D00000X |   |   | N |   | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |   | 251B00000X |   |   | Y |   | Agencies | Case Management |   |
ID Information
ID | Type | State | Issuer | Description | 100710730E | 05 | OK |   | MEDICAID | 100710730A | 05 | OK |   | MEDICAID | 100710730D | 05 | OK |   | MEDICAID |