Healthcare Provider Details

I. General information

NPI: 1609874528
Provider Name (Legal Business Name): AMBASSADOR MANOR NURSING CENTER L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 E 61ST ST
TULSA OK
74136-0605
US

IV. Provider business mailing address

1340 E 61ST ST
TULSA OK
74136-0605
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-8978
  • Fax: 918-749-5841
Mailing address:
  • Phone: 918-743-8978
  • Fax: 918-749-5841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH72017201
License Number StateOK

VIII. Authorized Official

Name: MRS. BEVERLY LATIMER
Title or Position: CFO
Credential:
Phone: 918-743-8978