Provider Demographics
NPI:1104830421
Name:PHOENIX HEALTHCARE LLC
Entity Type:Organization
Organization Name:PHOENIX HEALTHCARE LLC
Other - Org Name:REST HAVEN NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICARE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-743-3638
Mailing Address - Street 1:1944 N IROQUOIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-4407
Mailing Address - Country:US
Mailing Address - Phone:918-583-1509
Mailing Address - Fax:918-583-1804
Practice Address - Street 1:1944 N IROQUOIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-4407
Practice Address - Country:US
Practice Address - Phone:918-583-1509
Practice Address - Fax:918-583-1804
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-29
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH7221314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200040930HMedicaid
OK375274Medicare Oscar/Certification