Healthcare Provider Details

I. General information

NPI: 1851420384
Provider Name (Legal Business Name): TULSA BOYS' HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 S 137TH W AVE
SAND SPRINGS OK
74063-5017
US

IV. Provider business mailing address

PO BOX 1101
TULSA OK
74101-1101
US

V. Phone/Fax

Practice location:
  • Phone: 918-245-0231
  • Fax: 918-241-5031
Mailing address:
  • Phone: 918-245-0231
  • Fax: 918-241-5031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number StateOK

VIII. Authorized Official

Name: MR. GREGORY T. CONWAY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 918-245-0231