Healthcare Provider Details

I. General information

NPI: 1831248517
Provider Name (Legal Business Name): MASHBURN RESIDENTIAL LEARNING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 N BRIARWOOD DR
BOLIVAR MO
65613-1281
US

IV. Provider business mailing address

807 N BRIARWOOD DR
BOLIVAR MO
65613-1281
US

V. Phone/Fax

Practice location:
  • Phone: 417-326-6512
  • Fax:
Mailing address:
  • Phone: 417-326-6512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number14209362
License Number StateMO

VIII. Authorized Official

Name: LINDA L MASHBURN
Title or Position: OWNER
Credential:
Phone: 417-326-6512