MEDICARE: PHOENIX REHAB, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1760748248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX REHAB, LLC

Provider Business Mailing Address
First Line	:	1021 CHARLES PAGE BLVD
Second Line	:	STE 200
City	:	TULSA
State	:	OK
Zip	:	74127
Country	:	US
Telephone Number	:	918-585-5109
Fax Number	:	918-743-3767

Provider Business Practice Location Address
First Line	:	1021 CHARLES PAGE BLVD
Second Line	:	STE 200
City	:	TULSA
State	:	OK
Zip	:	74127-8815
Country	:	US
Telephone Number	:	918-585-5109
Fax Number	:	918-743-3767

Authorized Official
Title or Position	:	OWNER
Name	:	MR. LARRY CAIN
Credential	:
Telephone Number	:	918-585-5109

Provider Enumeration Date	:	04/09/2012
Last Update Date	:	04/09/2012

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