Provider Demographics
NPI:1710969571
Name:LAKE OZARK RETIREMENT CENTER, INC.
Entity Type:Organization
Organization Name:LAKE OZARK RETIREMENT CENTER, INC.
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 1:872 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065
Mailing Address - Country:US
Mailing Address - Phone:573-302-0900
Mailing Address - Fax:573-302-0146
Practice Address - Street 1:872 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-8688
Practice Address - Country:US
Practice Address - Phone:573-302-0900
Practice Address - Fax:573-302-0146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO030631314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO108303207Medicaid
MO108303207Medicaid