Provider Demographics
NPI:1710152202
Name:OAKRIDGE HOMES OF WADENA, INC.
Entity Type:Organization
Organization Name:OAKRIDGE HOMES OF WADENA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:FORBORD
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:218-829-7599
Mailing Address - Street 1:1021 INDUSTRIAL PARK RD SW
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-8338
Mailing Address - Country:US
Mailing Address - Phone:218-829-7599
Mailing Address - Fax:218-829-7498
Practice Address - Street 1:1021 INDUSTRIAL PARK ROAD
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-8338
Practice Address - Country:US
Practice Address - Phone:218-829-7599
Practice Address - Fax:218-829-7498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN151545400315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN066943021OtherVENDOR NUMBER
MN151545400OtherPROVIDER LICENSE NUMBER