Provider Demographics
NPI:1104389006
Name:LIBERTY OF OKLAHOMA CORPORATION
Entity type:Organization
Organization Name:LIBERTY OF OKLAHOMA CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:HUGH
Authorized Official - Middle Name:M
Authorized Official - Last Name:SAGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:580-213-2782
Mailing Address - Street 1:7318 E PINE ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74115-5743
Mailing Address - Country:US
Mailing Address - Phone:539-292-4607
Mailing Address - Fax:
Practice Address - Street 1:7318 E PINE ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74115-5743
Practice Address - Country:US
Practice Address - Phone:539-292-4607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY OF OKLAHOMA CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKNH7255-7255Medicaid