=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326289356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BONNY CREST HOME HEALTHCARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2009
-----------------------------------------------------
Last Update Date | 01/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 W FORT WORTH ST
-----------------------------------------------------
City | BROKEN ARROW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74012-3719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-949-4555
-----------------------------------------------------
Fax | 918-933-5352
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 W FORT WORTH ST
-----------------------------------------------------
City | BROKEN ARROW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74012-3719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-949-4555
-----------------------------------------------------
Fax | 918-933-5352
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. CHAKAKHAN L JONES
-----------------------------------------------------
Credential | BA, BS
-----------------------------------------------------
Telephone | 918-949-4555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------