Provider Demographics
NPI:1578272969
Name:BONNY CREST CHOICE LIVING LLC
Entity Type:Organization
Organization Name:BONNY CREST CHOICE LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JUMBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-949-4555
Mailing Address - Street 1:700 W FORT WORTH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-3719
Mailing Address - Country:US
Mailing Address - Phone:918-949-4555
Mailing Address - Fax:918-933-5352
Practice Address - Street 1:700 W FORT WORTH ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-3719
Practice Address - Country:US
Practice Address - Phone:918-949-4555
Practice Address - Fax:918-933-5352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No385H00000XRespite Care FacilityRespite Care