Provider Demographics
NPI:1477552412
Name:OAKRIDGE CONVALESCENT HOME
Entity Type:Organization
Organization Name:OAKRIDGE CONVALESCENT HOME
Other - Org Name:OAKRIDGE CONVALESCENT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ACERRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-547-6595
Mailing Address - Street 1:323 OAK RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60162-2019
Mailing Address - Country:US
Mailing Address - Phone:708-547-6595
Mailing Address - Fax:708-547-1971
Practice Address - Street 1:323 OAK RIDGE AVE
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:IL
Practice Address - Zip Code:60162-2019
Practice Address - Country:US
Practice Address - Phone:708-547-6595
Practice Address - Fax:708-547-1971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0005108314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid