Provider Demographics
NPI:1780280560
Name:OAK HAVEN RESIDENTIAL CARE LLC
Entity type:Organization
Organization Name:OAK HAVEN RESIDENTIAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:419-615-3357
Mailing Address - Street 1:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:OH
Mailing Address - Zip Code:45827-0086
Mailing Address - Country:US
Mailing Address - Phone:419-488-2310
Mailing Address - Fax:419-488-2321
Practice Address - Street 1:152 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLOVERDALE
Practice Address - State:OH
Practice Address - Zip Code:45827-9778
Practice Address - Country:US
Practice Address - Phone:419-488-2310
Practice Address - Fax:419-488-2321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0109295Medicaid