Provider Demographics
NPI:1164404927
Name:WESTPHALIA RETIREMENT CENTER
Entity Type:Organization
Organization Name:WESTPHALIA RETIREMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:OTKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-659-6607
Mailing Address - Street 1:1899 HIGHWAY 63
Mailing Address - Street 2:
Mailing Address - City:WESTPHALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65085-2215
Mailing Address - Country:US
Mailing Address - Phone:573-455-2280
Mailing Address - Fax:573-455-2253
Practice Address - Street 1:1899 HIGHWAY 63
Practice Address - Street 2:
Practice Address - City:WESTPHALIA
Practice Address - State:MO
Practice Address - Zip Code:65085-2215
Practice Address - Country:US
Practice Address - Phone:573-455-2280
Practice Address - Fax:573-455-2253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO030609313M00000X
MO030608314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO265777Medicare ID - Type Unspecified