Provider Demographics
NPI:1558461657
Name:PHOENIX RESIDENTIAL SERVICES
Entity Type:Organization
Organization Name:PHOENIX RESIDENTIAL SERVICES
Other - Org Name:ELLEN BEE HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:T
Authorized Official - Last Name:TOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-245-1884
Mailing Address - Street 1:20 W 2ND ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-7633
Mailing Address - Country:US
Mailing Address - Phone:918-245-1884
Mailing Address - Fax:918-245-0749
Practice Address - Street 1:20 W 2ND ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-7633
Practice Address - Country:US
Practice Address - Phone:918-245-1884
Practice Address - Fax:918-245-0749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7960251E00000X
OK200045930385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200045930 DMedicaid
OK200045930 BMedicaid
OK200045930 FMedicaid
OK200045930 GMedicaid
OK200045930 EMedicaid
OK200045930 AMedicaid
OK200045930 CMedicaid