Basic Information
| Provider Information | |||||||||
| NPI: | 1619915493 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEACONESS HEALTH SYSTEM LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DEACONESS HOME CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7600 NW 23RD ST | ||||||||
| Address2: | |||||||||
| City: | BETHANY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730084944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056046000 | ||||||||
| FaxNumber: | 4056046153 | ||||||||
| Practice Location | |||||||||
| Address1: | 7600 NW 23RD ST | ||||||||
| Address2: | |||||||||
| City: | BETHANY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730084944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056046000 | ||||||||
| FaxNumber: | 4056046153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 11/05/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLTSFORD | ||||||||
| AuthorizedOfficialFirstName: | EVA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, BUSINESS OFFICE SERVICE | ||||||||
| AuthorizedOfficialTelephone: | 6154657466 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 2294 | OK | Y | Agencies | Home Health |
No ID Information.