Provider Demographics
NPI:1487636239
Name:INDIAN HILLS RETIREMENT
Entity Type:Organization
Organization Name:INDIAN HILLS RETIREMENT
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 1:2601 FAIR ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601-3525
Mailing Address - Country:US
Mailing Address - Phone:660-646-1230
Mailing Address - Fax:660-707-1198
Practice Address - Street 1:2601 FAIR ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-3525
Practice Address - Country:US
Practice Address - Phone:660-646-1230
Practice Address - Fax:660-707-1198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031645313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO265785Medicare ID - Type Unspecified