Healthcare Provider Details

I. General information

NPI: 1942113832
Provider Name (Legal Business Name): ODORTUA SIMANUNGKALIT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KUSUMA ASMADI

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5683 S QUEMOY CT
CENTENNIAL CO
80015-6001
US

IV. Provider business mailing address

5683 S QUEMOY CT
CENTENNIAL CO
80015-6001
US

V. Phone/Fax

Practice location:
  • Phone: 720-903-6141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: