MEDICARE: OAK RIDGE DISTINCTIVE SENIOR LIVING AND REHAB, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134676885
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAK RIDGE DISTINCTIVE SENIOR LIVING AND REHAB, LLC

Provider Business Mailing Address
First Line	:	14615 MANCHESTER RD
Second Line	:
City	:	MANCHESTER
State	:	MO
Zip	:	63011-3790
Country	:	US
Telephone Number	:	314-225-7788
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 HUDSON ST
Second Line	:
City	:	EL DORADO
State	:	AR
Zip	:	71730-6573
Country	:	US
Telephone Number	:	314-536-2776
Fax Number	:

Authorized Official
Title or Position	:	SENIOR MEMBER
Name	:	MR. RODNEY FORTE
Credential	:
Telephone Number	:	618-889-3778

Provider Enumeration Date	:	09/09/2016
Last Update Date	:	09/09/2016

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