Provider Demographics
NPI:1952890337
Name:PHOENIX PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:PHOENIX PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NIKO
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLIASTASIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-636-3930
Mailing Address - Street 1:209 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-4639
Mailing Address - Country:US
Mailing Address - Phone:918-503-6276
Mailing Address - Fax:918-503-6294
Practice Address - Street 1:557 HARRISON ST
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-2566
Practice Address - Country:US
Practice Address - Phone:918-762-5050
Practice Address - Fax:877-515-8550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care