Provider Demographics
NPI:1417174772
Name:ODEBOLT ASSISTED LIVING, L.L.C.
Entity Type:Organization
Organization Name:ODEBOLT ASSISTED LIVING, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-224-4442
Mailing Address - Street 1:799 S. DES MOINES
Mailing Address - Street 2:
Mailing Address - City:ODEBOLT
Mailing Address - State:IA
Mailing Address - Zip Code:51458
Mailing Address - Country:US
Mailing Address - Phone:712-668-4867
Mailing Address - Fax:712-668-2268
Practice Address - Street 1:799 S. DES MOINES
Practice Address - Street 2:
Practice Address - City:ODEBOLT
Practice Address - State:IA
Practice Address - Zip Code:51458
Practice Address - Country:US
Practice Address - Phone:712-668-4867
Practice Address - Fax:712-668-2268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0250310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0747568Medicaid