Basic Information
| Provider Information | |||||||||
| NPI: | 1336470111 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OAK PARK HEALTHCARE, LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OAK PARK CONVALESCENT HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 BROAD ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374022671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233081845 | ||||||||
| FaxNumber: | 4233981844 | ||||||||
| Practice Location | |||||||||
| Address1: | 1625 OAK PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | PLEASANT HILL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945234487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259355222 | ||||||||
| FaxNumber: | 9259355211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2010 | ||||||||
| LastUpdateDate: | 09/08/2016 | ||||||||
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| AuthorizedOfficialLastName: | DEFOOR | ||||||||
| AuthorizedOfficialFirstName: | PERRY | ||||||||
| AuthorizedOfficialMiddleName: | BYRON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4233081845 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 055049 | 01 | TPAN | OTHER |