Provider Demographics
NPI:1972518835
Name:PHOENIX HEALTH CARE LLC
Entity Type:Organization
Organization Name:PHOENIX HEALTH CARE LLC
Other - Org Name:SOUTH PARK EAST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-743-3638
Mailing Address - Street 1:225 SW 35TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-6807
Mailing Address - Country:US
Mailing Address - Phone:405-631-7444
Mailing Address - Fax:405-631-1230
Practice Address - Street 1:225 SW 35TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-6807
Practice Address - Country:US
Practice Address - Phone:405-631-7444
Practice Address - Fax:405-631-1230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5534-5534311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200040930CMedicaid
OK375452Medicare Oscar/Certification