Provider Demographics
NPI:1609874528
Name:AMBASSADOR MANOR NURSING CENTER L.L.C.
Entity Type:Organization
Organization Name:AMBASSADOR MANOR NURSING CENTER L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LATIMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-743-8978
Mailing Address - Street 1:1340 E 61ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-0605
Mailing Address - Country:US
Mailing Address - Phone:918-743-8978
Mailing Address - Fax:918-749-5841
Practice Address - Street 1:1340 E 61ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-0605
Practice Address - Country:US
Practice Address - Phone:918-743-8978
Practice Address - Fax:918-749-5841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH72017201314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100806180AMedicaid
OK100806180BMedicaid
OK100806180BMedicaid