MEDICARE: LEISURE VILLAGE OPERATING 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	314000000X	Skilled Nursing Facility	NH7216-7216	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760480768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEISURE VILLAGE OPERATING LLC

Provider Business Mailing Address
First Line	:	4532 E 51ST ST STE H
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74135-3705
Country	:	US
Telephone Number	:	918-523-0222
Fax Number	:	918-523-0224

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	:	VICE PRESIDENT
Name	:	MS. DIANE H. HAMBRIC
Credential	:
Telephone Number	:	918-523-0222

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

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