Provider Demographics
NPI:1306964077
Name:SEQUEL OF OKLAHOMA, LLC
Entity type:Organization
Organization Name:SEQUEL OF OKLAHOMA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/DON
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BEDELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN MS
Authorized Official - Phone:405-417-3341
Mailing Address - Street 1:3301 N MARTIN LUTHER KING AVENUE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73111-4216
Mailing Address - Country:US
Mailing Address - Phone:405-548-1280
Mailing Address - Fax:405-548-1299
Practice Address - Street 1:3301 N MARTIN LUTHER KING AVENUE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-4216
Practice Address - Country:US
Practice Address - Phone:405-548-1280
Practice Address - Fax:405-548-1299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
323P00000X
OKK850000367323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200106860BMedicaid