Healthcare Provider Details

I. General information

NPI: 1083028856
Provider Name (Legal Business Name): LEISURE VILLAGE HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2154 S 85TH EAST AVE
TULSA OK
74129-3012
US

IV. Provider business mailing address

2154 S 85TH EAST AVE
TULSA OK
74129-3012
US

V. Phone/Fax

Practice location:
  • Phone: 918-622-4747
  • Fax: 918-622-0304
Mailing address:
  • Phone: 918-622-4747
  • Fax: 918-622-0304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH7216
License Number StateOK

VIII. Authorized Official

Name: JUDAH BIENSTOCK
Title or Position: MANAGING MEMBER
Credential:
Phone: 314-631-3000