=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356454094
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2006
-----------------------------------------------------
Last Update Date | 08/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1503 HAR-BER RD
-----------------------------------------------------
City | GROVE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74344-3525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-786-3223
-----------------------------------------------------
Fax | 918-786-2664
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1503 W HAR-BER RD
-----------------------------------------------------
City | GROVE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-786-3223
-----------------------------------------------------
Fax | 918-786-2664
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. LES TALLMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-786-3223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | NH2106-2106
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------