Healthcare Provider Details

I. General information

NPI: 1780701557
Provider Name (Legal Business Name): SOUTHERN MISSOURI SUPPORTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 2 BOX 2610
ALTON MO
65606-9633
US

IV. Provider business mailing address

4909 COCHERO CT
COLUMBIA MO
65203-9758
US

V. Phone/Fax

Practice location:
  • Phone: 417-778-1685
  • Fax:
Mailing address:
  • Phone: 573-447-0905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateMO

VIII. Authorized Official

Name: MR. ROBERT HOLLIS
Title or Position: OWNER
Credential:
Phone: 573-447-0905