Healthcare Provider Details

I. General information

NPI: 1225170467
Provider Name (Legal Business Name): COLONIAL MANOR MANAGEMENT COMPANY, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 05/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 E SKELLY DR
TULSA OK
74105-5919
US

IV. Provider business mailing address

1815 E SKELLY DR
TULSA OK
74105-5919
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-7838
  • Fax: 918-748-5970
Mailing address:
  • Phone: 918-743-7838
  • Fax: 918-748-5970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH7208-7208
License Number StateOK

VIII. Authorized Official

Name: MR. ED RUCKER
Title or Position: ADMINISTRATOR
Credential:
Phone: 918-743-7838