Provider Demographics
NPI:1043655319
Name:OAKRIDGE COMMUNITY CARE HOME
Entity Type:Organization
Organization Name:OAKRIDGE COMMUNITY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MAST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:864-621-4958
Mailing Address - Street 1:2470 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-9276
Mailing Address - Country:US
Mailing Address - Phone:864-472-6979
Mailing Address - Fax:
Practice Address - Street 1:2470 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:INMAN
Practice Address - State:SC
Practice Address - Zip Code:29349-9276
Practice Address - Country:US
Practice Address - Phone:864-472-6979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCCRC-0241261QC1500X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRC0241Medicaid
SCRC0241Medicaid