Provider Demographics
NPI:1265514145
Name:ST. JOHN HOME CARE LLC
Entity type:Organization
Organization Name:ST. JOHN HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SR. M. THERESE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTTSCHALK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-744-2180
Mailing Address - Street 1:4720 S HARVARD AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-3071
Mailing Address - Country:US
Mailing Address - Phone:918-747-7901
Mailing Address - Fax:
Practice Address - Street 1:4720 S HARVARD AVE STE 202
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3071
Practice Address - Country:US
Practice Address - Phone:918-747-7901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST JOHN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-19
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2265251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100699400AMedicaid
OK000371506001OtherBCBS
OK74104 0000OtherCHAMPUS
OK000371506001OtherBCBS