Provider Demographics
NPI:1083743629
Name:OAK RIDGE MANOR, INC
Entity Type:Organization
Organization Name:OAK RIDGE MANOR, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMPLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-334-7679
Mailing Address - Street 1:210 FRANKS LN
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-8439
Mailing Address - Country:US
Mailing Address - Phone:573-334-7679
Mailing Address - Fax:573-334-8145
Practice Address - Street 1:5108 STATE HIGHWAY B
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:MO
Practice Address - Zip Code:63769
Practice Address - Country:US
Practice Address - Phone:573-266-0206
Practice Address - Fax:573-334-8145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO033528310400000X, 3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness