1558461657 NPI number — PHOENIX RESIDENTIAL SERVICES

Table of content: (NPI 1558461657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558461657 NPI number — PHOENIX RESIDENTIAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX RESIDENTIAL SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558461657
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 W 2ND ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SAND SPRINGS
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74063-7633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-245-1884
Provider Business Mailing Address Fax Number:
918-245-0749

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 W 2ND ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SAND SPRINGS
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74063-7633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-245-1884
Provider Business Practice Location Address Fax Number:
918-245-0749
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TOTH
Authorized Official First Name:
LISA
Authorized Official Middle Name:
T
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
918-245-1884

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  7960 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385HR2060X , with the licence number: 200045930 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200045930 D , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200045930 B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200045930 F , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200045930 G , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200045930 E , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200045930 A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200045930 C , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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