Healthcare Provider Details

I. General information

NPI: 1043005606
Provider Name (Legal Business Name): PHS KS MOIRAI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date: 04/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 WALNUT ST
COFFEYVILLE KS
67337-6641
US

IV. Provider business mailing address

6943 S JAMESTOWN AVE
TULSA OK
74136-2611
US

V. Phone/Fax

Practice location:
  • Phone: 918-504-1659
  • Fax:
Mailing address:
  • Phone: 918-504-1659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State

VIII. Authorized Official

Name: JAMES AARON BAKER
Title or Position: MANAGER
Credential:
Phone: 918-504-1659