Healthcare Provider Details

I. General information

NPI: 1710969571
Provider Name (Legal Business Name): LAKE OZARK RETIREMENT CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 10/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

872 COLLEGE BLVD
OSAGE BEACH MO
65065-8688
US

IV. Provider business mailing address

872 COLLEGE BLVD
OSAGE BEACH MO
65065
US

V. Phone/Fax

Practice location:
  • Phone: 573-302-0900
  • Fax: 573-302-0146
Mailing address:
  • Phone: 573-302-0900
  • Fax: 573-302-0146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number030631
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier108303207
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: MR. TOM OTKE
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 573-659-6607