NPIMap

Organization Active NPI

Otterbein Portage Valley, Inc.

  • Skilled Nursing Facility
  • Pemberville, OH
National Provider Identifier
1629060058
Registry record updated Apr 24, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
4762 Issued in OH
Legal business name
OTTERBEIN PORTAGE VALLEY, INC.
Practice address
20311 Pemberville Rd
Pemberville, OH 43450-9413
Phone
(419) 833-7000
Fax
(419) 833-5763
NPI assigned
Aug 22, 2005
Last updated
Apr 24, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 24, 2017

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

Authorized official

Name
Mrs. Rita C Hawkins
Title
Avp Finance/Controller
Phone
(513) 933-5401

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 4762 OH Primary

Addresses

Primary practice location

20311 Pemberville Rd
Pemberville, OH 43450-9413

Mailing address

20311 Pemberville Rd
Pemberville, OH 43450-9413
Phone (419) 833-7000

Other identifiers 2

IdentifierTypeStateIssuer
0537130002OtherDMERC
0610093MedicaidOH

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OH

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120518000376 OH Part A Provider - Skilled Nursing Facility 5193988731 Practice locations: Pemberville, OH

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1629060058. Details of each certification follow.

Skilled nursing facility certification: CCN 365571

Legal name
OTTERBEIN PORTAGE VALLEY INC
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Dec 15, 1981
Last certification
Nov 28, 2022
Beds
50
Ownership / control type
Nonprofit Corporation
Multi-facility organization
Otterbein Senior Life
Organization structure
CorporationNon-profit
Incorporated
Sep 29, 1975 in OH
Enrollment address
20311 Pemberville Rd
Pemberville, OH 43450-9413
Nursing home name
OTTERBEIN PORTAGE VALLEY
Affiliated entity
OTTERBEIN SENIORLIFE

Care Compare: Nursing home

Medicare Care Compare
Listed as
Otterbein Portage ValleyCCN 365571 · All quality measures
Overall star rating
4 of 5
Health inspections
3 of 5
Staffing
3 of 5
Quality measures
5 of 5
Type
Medicare and Medicaid
Ownership
Non profit - Corporation
Certified
Dec 15, 1981
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
5045.7 residents per day on average
Chain
Otterbein Seniorlife20 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory
Tax ID family
Otterbein Portage Valle2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 30

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Tara Loar Individual Managing Control - Governing BodyBoard Member Jan 1, 2025
Trustee of the SNF Jan 1, 2025
Becky Bayliff Individual Operational/Managerial Control Dec 1, 2021
Polaris Pharmacy Services of Ohio LLC Organization, Columbus, OH LLC, Medical provider/supplier, Consulting firm, For-profit Adp of the SNF Dec 1, 2018
Thomas Kyllo Individual Managing Control - Governing BodyBoard Member Jan 1, 2015
Trustee of the SNF Jan 1, 2015
Jason E Miller Individual Corporate OfficerChief Operating Officer Aug 4, 2014
Heidi Glosser Individual Operational/Managerial Control Dec 1, 2021
John Stephenson Individual Corporate DirectorSenior Treasury Manager Aug 9, 1982
Victoria Bartlett Individual Operational/Managerial Control Dec 1, 2021
Katie McKibbin Individual Managing Control - Governing BodyBoard Member Jan 1, 2023
Trustee of the SNF Jan 1, 2023
William Brownson Individual Operational/Managerial Control Dec 1, 2021
Daniel Barbee Individual Managing Control - Governing BodyBoard Member Dec 1, 2021
Trustee of the SNF Dec 1, 2021
Rita C Hawkins Individual Corporate OfficerAvp/Controller Jan 16, 2006
Tomas Hazelbaker Individual Operational/Managerial Control Dec 1, 2021
Ralph Reed Fraley Individual Operational/Managerial Control Dec 1, 2021
Otterbein LSC, LLC Organization, Lebanon, OH LLC, Non-profit, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jan 1, 2016 100%
Norris Hinds Individual Managing Control - Governing BodyBoard Member Apr 1, 2021
Trustee of the SNF Apr 1, 2021
Functional Pathways of Tennessee LLC Organization, Knoxville, TN LLC, Medical provider/supplier, Medical staffing company, For-profit Operational/Managerial Control Dec 1, 2018
Adp of the SNF Apr 4, 2025
John E Pierce Individual Operational/Managerial Control Dec 1, 2021
Adp of the SNF Dec 1, 2021
Jill Wilson Individual Corporate OfficerPresident & Ceo May 1, 2009
Jessica Kirkendall Individual Operational/Managerial Control Jan 3, 2023
Adp of the SNF Jan 3, 2023
Otterbein Home Organization, Lebanon, OH Corporation, Non-profit, Chain home office 5% Or Greater Indirect Ownership Interest Dec 1, 2021 100%
Operational/Managerial Control Dec 1, 2021
Adp of the SNF Dec 1, 2021
Judy Benedict Individual Managing Control - Governing BodyBoard Member Jan 1, 2024
Trustee of the SNF Jan 1, 2024
James Christopher Green Individual Corporate OfficerCfo/Treasurer Nov 21, 2005
Operational/Managerial Control Dec 1, 2021
Robert Coleman Individual Operational/Managerial Control Dec 1, 2021
Angie Powell Individual Corporate DirectorAvp - Community Nov 24, 2014
Mike Godfrey Individual Managing Control - Governing BodyBoard Member Jan 1, 2024
Trustee of the SNF Jan 1, 2024
Marilyn Bowlus Individual Managing Control - Governing BodyBoard Member Jan 1, 2014
Trustee of the SNF Jan 1, 2014
Daniel Burke Individual Operational/Managerial Control Dec 1, 2021
Lynn App Individual Operational/Managerial Control Dec 1, 2021
Steve Vonderhaar Individual Operational/Managerial Control Dec 1, 2021

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 26

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 26

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1124668800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1492992000000",
    "number": "1629060058",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "20311 PEMBERVILLE RD",
            "city": "PEMBERVILLE",
            "state": "OH",
            "postal_code": "434509413",
            "telephone_number": "419-833-7000",
            "fax_number": "419-833-5763"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20311 PEMBERVILLE RD",
            "city": "PEMBERVILLE",
            "state": "OH",
            "postal_code": "434509413",
            "telephone_number": "419-833-7000",
            "fax_number": "419-833-5763"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OTTERBEIN PORTAGE VALLEY, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-22",
        "last_updated": "2017-04-24",
        "status": "A",
        "authorized_official_last_name": "HAWKINS",
        "authorized_official_first_name": "RITA",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "AVP FINANCE/CONTROLLER",
        "authorized_official_telephone_number": "513-933-5401",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "OH",
            "license": "4762",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DMERC",
            "identifier": "0537130002",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0610093",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Pemberville, OH

Sources for this page

Verify at the official NPI Registry.