MEDICARE: TCG TULSA ASSISTED LIVING LLC

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	310400000X	Assisted Living Facility	AL7201-7201	OK

General Provider Information

NPI Number	:	1558680918
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TCG TULSA ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	7220 S YALE AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-6348
Country	:	US
Telephone Number	:	918-946-0123
Fax Number	:	918-879-8180

Provider Business Practice Location Address
First Line	:	7220 S YALE AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-6348
Country	:	US
Telephone Number	:	918-946-0123
Fax Number	:	918-879-8180

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	ANITA B BLATNICK
Credential	:	ADMINISTRATOR
Telephone Number	:	918-496-0123

Provider Enumeration Date	:	05/25/2010
Last Update Date	:	05/25/2010

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