Healthcare Provider Details

I. General information

NPI: 1174149504
Provider Name (Legal Business Name): OAK GROVE MANOR OPERATING COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CRIDER RD
MANSFIELD OH
44903-9268
US

IV. Provider business mailing address

5915 LANDERBROOK DR STE 350
MAYFIELD HEIGHTS OH
44124-4063
US

V. Phone/Fax

Practice location:
  • Phone: 419-589-6222
  • Fax:
Mailing address:
  • Phone: 330-620-7828
  • Fax: 216-428-2055

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: MR. JEFFREY DEGYANSKY
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential: LNHA
Phone: 330-620-7828