Basic Information
Provider Information | |||||||||
NPI: | 1114968179 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FOUR SEASONS NURSING CENTERS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MANORCARE HEALTH SERVICES - SOUTHWEST | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 333 N SUMMIT ST | ||||||||
Address2: | ATTN: BARRY LAZARUS | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436041531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192525541 | ||||||||
FaxNumber: | 4192525548 | ||||||||
Practice Location | |||||||||
Address1: | 5600 S WALKER AVE | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731098314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4056327771 | ||||||||
FaxNumber: | 4056322406 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2006 | ||||||||
LastUpdateDate: | 08/07/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAZARUS | ||||||||
AuthorizedOfficialFirstName: | BARRY | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT - REIMBURSEMENTS | ||||||||
AuthorizedOfficialTelephone: | 4192525541 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH-5514-5514 | OK | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 100772760A | 05 | OK |   | MEDICAID |