Basic Information
| Provider Information | |||||||||
| NPI: | 1952546400 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OAK GROVE INSTITUTE FOUNDATION, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24275 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925627285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516775599 | ||||||||
| FaxNumber: | 9516980461 | ||||||||
| Practice Location | |||||||||
| Address1: | 24275 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925627285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516775599 | ||||||||
| FaxNumber: | 9516980461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2008 | ||||||||
| LastUpdateDate: | 12/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | TAMARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9516775599 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 330911240 | CA | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 3245S0500X | 330911240 | CA | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 323P00000X | 330911240 | CA | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
No ID Information.