Healthcare Provider Details

I. General information

NPI: 1972178275
Provider Name (Legal Business Name): PROPHYLAXIS PRIMARY CARE AND BEHAVIORAL HEALTHCARE SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12816 S MEMORIAL DR UNIT 121
BIXBY OK
74008-2593
US

IV. Provider business mailing address

PO BOX 334
BIXBY OK
74008-0334
US

V. Phone/Fax

Practice location:
  • Phone: 918-970-4719
  • Fax:
Mailing address:
  • Phone: 918-970-4719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALBERT SANCHEZ
Title or Position: CEO
Credential:
Phone: 479-263-2690