Healthcare Provider Details

I. General information

NPI: 1215056437
Provider Name (Legal Business Name): BROOKSIDE CASA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17858 BROOKSIDE RD
BARNETT MO
65011-3023
US

IV. Provider business mailing address

17858 BROOKSIDE RD
BARNETT MO
65011-3023
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-2266
  • Fax: 573-378-2267
Mailing address:
  • Phone: 573-378-2266
  • Fax: 573-378-2267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. DENSIE L SPOTILA
Title or Position: ADMINISTRATOR
Credential:
Phone: 573-378-2266