MEDICARE: OASIS CARE LIVING, 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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	BH2933	AZ

General Provider Information

NPI Number	:	1821298894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OASIS CARE LIVING, LLC

Provider Business Mailing Address
First Line	:	6917 S 11TH DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-6743
Country	:	US
Telephone Number	:	602-334-1303
Fax Number	:	602-535-5109

Provider Business Practice Location Address
First Line	:	6917 S 11TH DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-6743
Country	:	US
Telephone Number	:	602-334-1303
Fax Number	:	602-535-5109

Authorized Official
Title or Position	:	CEO/ADMINISTRATOR
Name	:	MR. LESTER L KNOX JR.
Credential	:
Telephone Number	:	602-510-8007

Provider Enumeration Date	:	07/19/2007
Last Update Date	:	07/19/2007

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