Provider Demographics
NPI:1942318118
Name:OAK GROVE RETIREMENT HOME, INC.
Entity Type:Organization
Organization Name:OAK GROVE RETIREMENT HOME, INC.
Other - Org Name:OAK GROVE RETIREMENT HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMENISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:I
Authorized Official - Credentials:LNHA
Authorized Official - Phone:662-395-2577
Mailing Address - Street 1:201 OAK CIRCLE
Mailing Address - Street 2:N/A
Mailing Address - City:DUNCAN
Mailing Address - State:MS
Mailing Address - Zip Code:38740
Mailing Address - Country:US
Mailing Address - Phone:662-395-2577
Mailing Address - Fax:
Practice Address - Street 1:200 OAK CIRCLE
Practice Address - Street 2:N/A
Practice Address - City:DUNCAN
Practice Address - State:MS
Practice Address - Zip Code:38740
Practice Address - Country:US
Practice Address - Phone:662-395-2577
Practice Address - Fax:662-395-2568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00023100313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00023110Medicaid