Provider Demographics
NPI:1740588672
Name:UNIVERSITY VILLAGE RETIREMENT COMMUNITY, LLC
Entity Type:Organization
Organization Name:UNIVERSITY VILLAGE RETIREMENT COMMUNITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:I
Authorized Official - Last Name:NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-298-3652
Mailing Address - Street 1:8555 S LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-1218
Mailing Address - Country:US
Mailing Address - Phone:918-299-2661
Mailing Address - Fax:918-298-3270
Practice Address - Street 1:8555 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-1218
Practice Address - Country:US
Practice Address - Phone:918-299-2661
Practice Address - Fax:918-298-3270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-01
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAL7214310400000X
OK7231314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200424210AMedicaid