Healthcare Provider Details

I. General information

NPI: 1780687590
Provider Name (Legal Business Name): PHOENIX HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10912 E 14TH ST
TULSA OK
74128-4845
US

IV. Provider business mailing address

10912 E 14TH ST
TULSA OK
74128-4845
US

V. Phone/Fax

Practice location:
  • Phone: 918-438-2440
  • Fax: 918-437-0869
Mailing address:
  • Phone: 918-438-2440
  • Fax: 918-437-0869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH7230-7230
License Number StateOK

VIII. Authorized Official

Name: MR. LARRY CAIN
Title or Position: RECEIVER
Credential:
Phone: 918-438-2440