Healthcare Provider Details

I. General information

NPI: 1679771430
Provider Name (Legal Business Name): GOOD SAMARITAN BOYS RANCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5549 N HIGHWAY 13
BRIGHTON MO
65617-8112
US

IV. Provider business mailing address

PO BOX 617
BRIGHTON MO
65617-0617
US

V. Phone/Fax

Practice location:
  • Phone: 417-376-2238
  • Fax:
Mailing address:
  • Phone: 417-376-2238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MARK ANDREW MAINE
Title or Position: DIRECTOR OF INFORMATION TECHNOLOGY
Credential:
Phone: 417-376-2238