Provider Demographics
NPI:1891910881
Name:HOMESTEAD OF OSKALOOSA OPERATIONS LLC
Entity Type:Organization
Organization Name:HOMESTEAD OF OSKALOOSA OPERATIONS LLC
Other - Org Name:MAPLE RIDGE ASSISTANT LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:TRYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-228-7913
Mailing Address - Street 1:3715 SW 29TH STREET
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614
Mailing Address - Country:US
Mailing Address - Phone:785-272-1535
Mailing Address - Fax:785-272-1480
Practice Address - Street 1:2102 SOUTH MARKET STREET
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577
Practice Address - Country:US
Practice Address - Phone:641-672-1090
Practice Address - Fax:641-672-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0186310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0428839Medicaid