Basic Information
| Provider Information | |||||||||
| NPI: | 1265514145 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOHN HOME CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4720 S HARVARD AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741353071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187477901 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4720 S HARVARD AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741353071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187477901 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 08/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | GOTTSCHALK | ||||||||
| AuthorizedOfficialFirstName: | SR. M. THERESE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9187442180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST JOHN MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 2265 | OK | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 100699400A | 05 | OK | MEDICAID | 000371506001 | 01 | OK | BCBS | OTHER | 74104 0000 | 01 | OK | CHAMPUS | OTHER |