Provider Demographics
NPI:1356454094
Name:PHOENIX HEALTHCARE LLC
Entity Type:Organization
Organization Name:PHOENIX HEALTHCARE LLC
Other - Org Name:GROVE NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LES
Authorized Official - Middle Name:
Authorized Official - Last Name:TALLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-786-3223
Mailing Address - Street 1:1503 W HAR-BER RD
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344
Mailing Address - Country:US
Mailing Address - Phone:918-786-3223
Mailing Address - Fax:918-786-2664
Practice Address - Street 1:1503 HAR-BER RD
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-3525
Practice Address - Country:US
Practice Address - Phone:918-786-3223
Practice Address - Fax:918-786-2664
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-16
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH2106-2106313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200040930FMedicaid
OK375366Medicare Oscar/Certification