Healthcare Provider Details

I. General information

NPI: 1508441460
Provider Name (Legal Business Name): OAK GROVE STREET OPERATING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 12/17/2021
Certification Date: 08/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 OAK GROVE ST
MOUNTAIN VIEW AR
72560-8601
US

IV. Provider business mailing address

317 MONMOUTH AVE STE 201
LAKEWOOD NJ
08701-3209
US

V. Phone/Fax

Practice location:
  • Phone: 870-269-5845
  • Fax:
Mailing address:
  • Phone: 848-210-2175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: YISROEL GANZ
Title or Position: DIRECTOR
Credential:
Phone: 848-210-2175