Provider Demographics
NPI:1811634157
Name:OAK GROVE RETIREMENT OPCO LLC
Entity type:Organization
Organization Name:OAK GROVE RETIREMENT OPCO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED SIGNATORY
Authorized Official - Prefix:
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DREIFUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-961-8100
Mailing Address - Street 1:PO BOX 8250
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72145-8250
Mailing Address - Country:US
Mailing Address - Phone:501-254-0007
Mailing Address - Fax:888-866-9887
Practice Address - Street 1:209 OAK CIR
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:MS
Practice Address - Zip Code:38740-5520
Practice Address - Country:US
Practice Address - Phone:662-395-2577
Practice Address - Fax:662-395-2576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-18
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility