Provider Demographics
NPI:1336470111
Name:OAK PARK HEALTHCARE, LLC
Entity Type:Organization
Organization Name:OAK PARK HEALTHCARE, LLC
Other - Org Name:OAK PARK CONVALESCENT HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:BYRON
Authorized Official - Last Name:DEFOOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-308-1845
Mailing Address - Street 1:801 BROAD ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402-2671
Mailing Address - Country:US
Mailing Address - Phone:423-308-1845
Mailing Address - Fax:423-398-1844
Practice Address - Street 1:1625 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-4487
Practice Address - Country:US
Practice Address - Phone:925-935-5222
Practice Address - Fax:925-935-5211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
055049OtherTPAN
055049OtherTPAN