Provider Demographics
NPI:1801854393
Name:FOUNTAINS CANTERBURY SL, LLC
Entity Type:Organization
Organization Name:FOUNTAINS CANTERBURY SL, LLC
Other - Org Name:THE FOUNTAINS AT CANTERBURY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRETA
Authorized Official - Middle Name:FRUHLING
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-797-4000
Mailing Address - Street 1:2020 W RUDASILL RD
Mailing Address - Street 2:ATTN: MEDICARE BILLING
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-7800
Mailing Address - Country:US
Mailing Address - Phone:520-797-4000
Mailing Address - Fax:520-797-7757
Practice Address - Street 1:1404 NW 122ND ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-8000
Practice Address - Country:US
Practice Address - Phone:405-751-3600
Practice Address - Fax:405-751-6511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKCC5503-5503314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100777120AMedicaid
OK100777120AMedicaid