Provider Demographics
NPI:1982371233
Name:OAK GROVE ASSISTED LIVING FACILITY, LLC
Entity Type:Organization
Organization Name:OAK GROVE ASSISTED LIVING FACILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-244-9712
Mailing Address - Street 1:21107 BIRCHOLM CT
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34637-7464
Mailing Address - Country:US
Mailing Address - Phone:720-244-9712
Mailing Address - Fax:
Practice Address - Street 1:5483 NEFF LAKE RD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-7842
Practice Address - Country:US
Practice Address - Phone:352-796-3733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111276900Medicaid