Healthcare Provider Details

I. General information

NPI: 1700367778
Provider Name (Legal Business Name): NORTHEAST RANDOLPH CO. R-IV
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W MARTIN ST
CAIRO MO
65239-1006
US

IV. Provider business mailing address

301 W MARTIN ST
CAIRO MO
65239-1006
US

V. Phone/Fax

Practice location:
  • Phone: 660-263-2788
  • Fax:
Mailing address:
  • Phone: 660-263-2788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: SHANNA WEBER
Title or Position: DIRECTOR OF SPECIAL EDUCATION
Credential:
Phone: 660-263-2788