Healthcare Provider Details

I. General information

NPI: 1760480768
Provider Name (Legal Business Name): LEISURE VILLAGE OPERATING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 06/14/2011
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

4532 E 51ST ST STE H
TULSA OK
74135-3705
US

V. Phone/Fax

Practice location:
  • Phone: 918-622-4747
  • Fax: 918-622-0304
Mailing address:
  • Phone: 918-523-0222
  • Fax: 918-523-0224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH7216-7216
License Number StateOK

VIII. Authorized Official

Name: MS. DIANE H. HAMBRIC
Title or Position: VICE PRESIDENT
Credential:
Phone: 918-523-0222