Healthcare Provider Details

I. General information

NPI: 1780280560
Provider Name (Legal Business Name): OAK HAVEN RESIDENTIAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 MAIN ST
CLOVERDALE OH
45827-9778
US

IV. Provider business mailing address

PO BOX 86
CLOVERDALE OH
45827-0086
US

V. Phone/Fax

Practice location:
  • Phone: 419-488-2310
  • Fax: 419-488-2321
Mailing address:
  • Phone: 419-488-2310
  • Fax: 419-488-2321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHERRY KAYE WEBB
Title or Position: ADMINISTRATOR
Credential: LPN
Phone: 419-615-3357