Provider Demographics
NPI:1629060058
Name:OTTERBEIN PORTAGE VALLEY, INC.
Entity Type:Organization
Organization Name:OTTERBEIN PORTAGE VALLEY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AVP FINANCE/CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-933-5401
Mailing Address - Street 1:20311 PEMBERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:PEMBERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43450-9413
Mailing Address - Country:US
Mailing Address - Phone:419-833-7000
Mailing Address - Fax:419-833-5763
Practice Address - Street 1:20311 PEMBERVILLE RD
Practice Address - Street 2:
Practice Address - City:PEMBERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43450-9413
Practice Address - Country:US
Practice Address - Phone:419-833-7000
Practice Address - Fax:419-833-5763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4762314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0610093Medicaid
0537130002OtherDMERC
OH0610093Medicaid