Provider Demographics
NPI:1093754459
Name:OAK GROVE HEALTHCARE LLC
Entity Type:Organization
Organization Name:OAK GROVE HEALTHCARE LLC
Other - Org Name:OAK GROVE HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:USSERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-571-1550
Mailing Address - Street 1:518 OLD US 221 HWY
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORDTON
Mailing Address - State:NC
Mailing Address - Zip Code:28139-8670
Mailing Address - Country:US
Mailing Address - Phone:828-287-7655
Mailing Address - Fax:828-287-4459
Practice Address - Street 1:518 OLD US 221 HWY
Practice Address - Street 2:
Practice Address - City:RUTHERFORDTON
Practice Address - State:NC
Practice Address - Zip Code:28139-8670
Practice Address - Country:US
Practice Address - Phone:828-287-7655
Practice Address - Fax:828-287-4459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0566314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1093754459Medicaid
NC341608YMedicaid
NC7805124Medicaid
345464Medicare Oscar/Certification