Healthcare Provider Details

I. General information

NPI: 1760748248
Provider Name (Legal Business Name): PHOENIX REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 04/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 CHARLES PAGE BLVD STE 200
TULSA OK
74127-8815
US

IV. Provider business mailing address

1021 CHARLES PAGE BLVD STE 200
TULSA OK
74127
US

V. Phone/Fax

Practice location:
  • Phone: 918-585-5109
  • Fax: 918-743-3767
Mailing address:
  • Phone: 918-585-5109
  • Fax: 918-743-3767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. LARRY CAIN
Title or Position: OWNER
Credential:
Phone: 918-585-5109