Provider Demographics
NPI:1285762450
Name:OAK GROVE MANOR MRDD
Entity type:Organization
Organization Name:OAK GROVE MANOR MRDD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:G
Authorized Official - Last Name:ALEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-459-2482
Mailing Address - Street 1:1661 OLD HENDERSON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-3644
Mailing Address - Country:US
Mailing Address - Phone:614-459-2482
Mailing Address - Fax:614-459-2641
Practice Address - Street 1:1670 CRIDER RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-9268
Practice Address - Country:US
Practice Address - Phone:614-459-2482
Practice Address - Fax:614-459-2641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1783N315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2561464Medicaid
OH2561464Medicaid