Healthcare Provider Details

I. General information

NPI: 1043655319
Provider Name (Legal Business Name): OAKRIDGE COMMUNITY CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 12/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2470 OLD MILL RD
INMAN SC
29349-9276
US

IV. Provider business mailing address

2470 OLD MILL RD
INMAN SC
29349-9276
US

V. Phone/Fax

Practice location:
  • Phone: 864-472-6979
  • Fax:
Mailing address:
  • Phone: 864-472-6979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberCRC-0241
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DARRYL ALAN MAST
Title or Position: ADMINISTRATOR
Credential: RPH
Phone: 864-621-4958