1801854393 NPI number — FOUNTAINS CANTERBURY SL, LLC

Table of content: MRS. NANCY DIXON KOCH LSLS CERT. AVED (NPI 1427535186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801854393 NPI number — FOUNTAINS CANTERBURY SL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNTAINS CANTERBURY SL, LLC
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:
1801854393
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2020 W RUDASILL RD
Provider Second Line Business Mailing Address:
ATTN: MEDICARE BILLING
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85704-7800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-797-4000
Provider Business Mailing Address Fax Number:
520-797-7757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1404 NW 122ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73114-8000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-751-3600
Provider Business Practice Location Address Fax Number:
405-751-6511
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FRAZIER
Authorized Official First Name:
GRETA
Authorized Official Middle Name:
FRUHLING
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
520-797-4000

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  CC5503-5503 , 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: 100777120A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com