Basic Information
| Provider Information | |||||||||
| NPI: | 1942318118 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OAK GROVE RETIREMENT HOME, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OAK GROVE RETIREMENT HOME | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 201 OAK CIRCLE | ||||||||
| Address2: | N/A | ||||||||
| City: | DUNCAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623952577 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 OAK CIRCLE | ||||||||
| Address2: | N/A | ||||||||
| City: | DUNCAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623952577 | ||||||||
| FaxNumber: | 6623952568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 10/07/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMENISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6623952577 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | I | ||||||||
| AuthorizedOfficialCredential: | LNHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 00023100 | MS | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 00023110 | 05 | MS | MEDICAID |