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NPI Code Detail

MEDICARE: COLONIAL MANOR NURSING CENTER, INC.

MEDICARE: COLONIAL MANOR NURSING CENTER, INC.
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
1313M00000XNursing Facility/Intermediate Care FacilityNH7208-7208OK
2314000000XSkilled Nursing Facility375465OK

General Provider Information

NPI Number : 1124129556
Entity Type Code : Organization
Provider Name (Legal Business Name) : COLONIAL MANOR NURSING CENTER, INC.
Provider Business Mailing Address
First Line : 1815 E SKELLY DR
Second Line :
City : TULSA
State : OK
Zip : 74105-5919
Country : US
Telephone Number : 918-743-7838
Fax Number :
Provider Business Practice Location Address
First Line : 1815 E SKELLY DR
Second Line :
City : TULSA
State : OK
Zip : 74105-5919
Country : US
Telephone Number : 918-743-7838
Fax Number :
Authorized Official
Title or Position : ADMINISTRATOR
Name : MR. ED RUCKER
Credential :
Telephone Number : 918-743-7838
Provider Enumeration Date : 09/26/2006
Last Update Date : 09/11/2025

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