Omega Long Term Care LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

License

137743 Issued in MO

Legal business name

OMEGA LONG TERM CARE LLC

Practice address

12800 Boenker LN
Bridgeton, MO 63044-2438

Phone

(314) 551-0338

Fax

(314) 551-0336

NPI assigned

Jul 24, 2014

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Kim L Wyatt

Title

Office Manager

Phone

(314) 808-5083

Specialties & licenses 1

Addresses

Other identifiers 4

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1406160000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1406160000000",
    "number": "1285042184",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12800 BOENKER LN",
            "city": "BRIDGETON",
            "state": "MO",
            "postal_code": "630442438",
            "telephone_number": "314-551-0338",
            "fax_number": "314-551-0336"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12800 BOENKER LN",
            "city": "BRIDGETON",
            "state": "MO",
            "postal_code": "630442438",
            "telephone_number": "314-551-0338",
            "fax_number": "314-551-0336"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OMEGA LONG TERM CARE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-07-24",
        "last_updated": "2014-07-24",
        "status": "A",
        "authorized_official_last_name": "WYATT",
        "authorized_official_first_name": "KIM",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "314-808-5083",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": "MO",
            "license": "137743",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "429398209",
            "state": "MO"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2001189801",
            "state": "MO"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "207937715",
            "state": "MO"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2083138069",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Assisted Living Facility in Bridgeton, MO
• Providers in Bridgeton, MO by specialty
• Assisted Living Facility in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 24, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.