Provider Demographics
NPI:1073796264
Name:LESLIE EVELYN TODD OAK GROVE FAMILY CARE
Entity Type:Organization
Organization Name:LESLIE EVELYN TODD OAK GROVE FAMILY CARE
Other - Org Name:OAK GROVE FAMILY CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:CALLIHAN
Authorized Official - Last Name:DOVE
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR, LPN
Authorized Official - Phone:910-648-2176
Mailing Address - Street 1:583 SASSAFRAS RD
Mailing Address - Street 2:
Mailing Address - City:BLADENBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28320-5925
Mailing Address - Country:US
Mailing Address - Phone:910-648-2176
Mailing Address - Fax:910-648-5785
Practice Address - Street 1:583 SASSAFRAS RD
Practice Address - Street 2:ROUTE 4 BOX 271
Practice Address - City:BLADENBORO
Practice Address - State:NC
Practice Address - Zip Code:28320-5925
Practice Address - Country:US
Practice Address - Phone:910-648-2176
Practice Address - Fax:910-648-5785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-009-008310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802347Medicaid