Provider Demographics
NPI:1972961415
Name:LIVE OAK HOLDINGS, LLC
Entity Type:Organization
Organization Name:LIVE OAK HOLDINGS, LLC
Other - Org Name:GOVERNOR'S RIDGE RETIREMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ERSELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-301-9819
Mailing Address - Street 1:300 E DEVEREAUX ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3033
Mailing Address - Country:US
Mailing Address - Phone:940-627-1104
Mailing Address - Fax:940-627-1159
Practice Address - Street 1:300 E DEVEREAUX ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3033
Practice Address - Country:US
Practice Address - Phone:940-627-1104
Practice Address - Fax:940-627-1159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX141222310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility