Provider Demographics
NPI:1134676885
Name:OAK RIDGE DISTINCTIVE SENIOR LIVING AND REHAB, LLC
Entity Type:Organization
Organization Name:OAK RIDGE DISTINCTIVE SENIOR LIVING AND REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-889-3778
Mailing Address - Street 1:14615 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3790
Mailing Address - Country:US
Mailing Address - Phone:314-225-7788
Mailing Address - Fax:
Practice Address - Street 1:501 HUDSON ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-6573
Practice Address - Country:US
Practice Address - Phone:314-536-2776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DISTINCTIVE SENIOR LIVING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR109136311Medicaid
AR045271Medicare PIN