MEDICARE: LEISURE VILLAGE HEALTH CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	NH7216	OK

General Provider Information

NPI Number	:	1083028856
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEISURE VILLAGE HEALTH CARE

Provider Business Mailing Address
First Line	:	2154 S 85TH EAST AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74129-3012
Country	:	US
Telephone Number	:	918-622-4747
Fax Number	:	918-622-0304

Provider Business Practice Location Address
First Line	:	2154 S 85TH EAST AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74129-3012
Country	:	US
Telephone Number	:	918-622-4747
Fax Number	:	918-622-0304

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JUDAH BIENSTOCK
Credential	:
Telephone Number	:	314-631-3000

Provider Enumeration Date	:	06/19/2014
Last Update Date	:	12/02/2015

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