MEDICARE: LIFETIME SERVICES OF MISSOURI, INC.

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1912799354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFETIME SERVICES OF MISSOURI, INC.

Provider Business Mailing Address
First Line	:	4201 STONE GROVE CT
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203-8440
Country	:	US
Telephone Number	:	573-673-8437
Fax Number	:	573-673-8437

Provider Business Practice Location Address
First Line	:	4201 STONE GROVE CT
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203-8440
Country	:	US
Telephone Number	:	573-673-8437
Fax Number	:	573-673-8437

Authorized Official
Title or Position	:	FOUNDER/EXECUTIVE DIRECTOR
Name	:	ROBERT V PALMER
Credential	:
Telephone Number	:	573-673-8437

Provider Enumeration Date	:	05/21/2025
Last Update Date	:	05/21/2025

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