Provider Demographics
NPI:1730131897
Name:OTKE-VILLA LLC
Entity Type:Organization
Organization Name:OTKE-VILLA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
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 1:1030 EDMONDS ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5213
Mailing Address - Country:US
Mailing Address - Phone:573-635-3381
Mailing Address - Fax:573-635-6685
Practice Address - Street 1:1030 EDMONDS ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5213
Practice Address - Country:US
Practice Address - Phone:573-635-3381
Practice Address - Fax:573-635-6685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032359314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO265208Medicare ID - Type Unspecified