Provider Demographics
NPI:1558964742
Name:OAKTREE MANOR ASSISTED LIVING, INC.
Entity Type:Organization
Organization Name:OAKTREE MANOR ASSISTED LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-401-8930
Mailing Address - Street 1:PO BOX 4150
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-4150
Mailing Address - Country:US
Mailing Address - Phone:662-322-4636
Mailing Address - Fax:662-840-3311
Practice Address - Street 1:60139 COTTON GIN PORT RD
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-8520
Practice Address - Country:US
Practice Address - Phone:662-256-8406
Practice Address - Fax:662-256-8883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility