Healthcare Provider Details

I. General information

NPI: 1922772144
Provider Name (Legal Business Name): OAKENDELL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3585 HAWVER RD.
SAN ANDREAS CA
95249
US

IV. Provider business mailing address

PO BOX 1144
SAN ANDREAS CA
95249-1144
US

V. Phone/Fax

Practice location:
  • Phone: 209-754-1249
  • Fax: 209-754-1087
Mailing address:
  • Phone: 209-754-1249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: PAUL MERTENS
Title or Position: CEO
Credential:
Phone: 209-754-1249