=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508149105
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISITING ANGELS, LIVING ASSISTANCE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2011
-----------------------------------------------------
Last Update Date | 09/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 713 S MUSTANG RD
-----------------------------------------------------
City | YUKON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73099-6778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-350-6700
-----------------------------------------------------
Fax | 405-354-0541
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 850560
-----------------------------------------------------
City | YUKON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73085-0560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-350-6700
-----------------------------------------------------
Fax | 405-354-0541
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. SHANNON RENE' MEYER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-350-6700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 7854
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------