Healthcare Provider Details

I. General information

NPI: 1164290326
Provider Name (Legal Business Name): OAK ST HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 12/18/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 E OAK ST
PHOENIX AZ
85008
US

IV. Provider business mailing address

3201 E OAK ST
PHOENIX AZ
85008
US

V. Phone/Fax

Practice location:
  • Phone: 952-666-9915
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: SILAS HARRIS
Title or Position: OWNER
Credential:
Phone: 952-666-9915