Provider Demographics
NPI:1013674472
Name:OAK FENCE SENIOR LIVING LLC
Entity Type:Organization
Organization Name:OAK FENCE SENIOR LIVING LLC
Other - Org Name:APPLE VALLEY CONGREGATE LIVING HEALTH FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:AYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-967-1872
Mailing Address - Street 1:6067 OAK FENCE LN
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-1795
Mailing Address - Country:US
Mailing Address - Phone:909-967-1872
Mailing Address - Fax:
Practice Address - Street 1:20135 ONEIDA RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-5207
Practice Address - Country:US
Practice Address - Phone:909-967-1872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OAK FENCE SENIOR LIVING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-11-19
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550005416OtherDEPARTMENT OF PUBLIC HEALTH
CA1013674472Medicaid
CA1497140222Medicaid