=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740296490
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 09/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 N COLUMBIA AVE
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74110-1232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-428-3600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3601 N COLUMBIA AVE
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74110-1232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-428-3600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS OFFICE
-----------------------------------------------------
Name | MS. CHRYSTAL WEST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-743-3638
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | NH7204
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------