MEDICARE: STATE OF MISSOURI

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	:	1922207679
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF MISSOURI

Provider Business Mailing Address
First Line	:	1706 E ELM ST
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65101-4130
Country	:	US
Telephone Number	:	573-751-3398
Fax Number	:	573-526-4560

Provider Business Practice Location Address
First Line	:	5410 RINKER RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64129-2308
Country	:	US
Telephone Number	:	816-512-7515
Fax Number	:	816-512-7517

Authorized Official
Title or Position	:	DIRECTOR OF ADMINISTRATIVE SERVICES
Name	:	MOLLY JANE BOECKMANN
Credential	:
Telephone Number	:	573-751-4055

Provider Enumeration Date	:	07/13/2007
Last Update Date	:	10/27/2020

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Directions to “STATE OF MISSOURI ” Practice Location

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