Healthcare Provider Details

I. General information

NPI: 1760855431
Provider Name (Legal Business Name): CAMBRIDGE OF BRANSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2015
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4470 N GRETNA RD
BRANSON MO
65616-7202
US

IV. Provider business mailing address

4675 N GRETNA RD STE 201
BRANSON MO
65616-7583
US

V. Phone/Fax

Practice location:
  • Phone: 417-544-0630
  • Fax: 417-544-0671
Mailing address:
  • Phone: 417-339-4232
  • Fax: 417-334-5087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number1291
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. JANICE LYNN GOODMAN
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 417-544-0630