Provider Demographics
NPI:1659497774
Name:OAK TERRACE HEALTHCARE CENTER, INC.
Entity Type:Organization
Organization Name:OAK TERRACE HEALTHCARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-362-4942
Mailing Address - Street 1:1750 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-4759
Mailing Address - Country:US
Mailing Address - Phone:217-787-6466
Mailing Address - Fax:217-787-6846
Practice Address - Street 1:1750 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4759
Practice Address - Country:US
Practice Address - Phone:217-787-6466
Practice Address - Fax:217-787-6846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0023010313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility