MEDICARE: OZARK TRAILS YOUTH SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1548895790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OZARK TRAILS YOUTH SERVICES

Provider Business Mailing Address
First Line	:	1405 DOCTORS DR
Second Line	:
City	:	WEST PLAINS
State	:	MO
Zip	:	65775-4754
Country	:	US
Telephone Number	:	417-256-4111
Fax Number	:

Provider Business Practice Location Address
First Line	:	40840 CR RD 181-280
Second Line	:
City	:	WILLOW SPRINGS
State	:	MO
Zip	:	65793-6579
Country	:	US
Telephone Number	:	417-372-2041
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	CHRIS MANTELL
Credential	:
Telephone Number	:	434-882-2303

Provider Enumeration Date	:	03/09/2020
Last Update Date	:	03/09/2020

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