=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710270418
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEANDRE LAJUAN RHODES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2011
-----------------------------------------------------
Last Update Date | 05/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1737 E. 32ND ST. NORTH
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-428-2412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5010 S URBANA AVE APT 1B
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74135-3409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SERVICE COORDINATOR
-----------------------------------------------------
Name | MR. DEANDRE LAJUAN RHODES SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-850-2412
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 61573931
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------