Healthcare Provider Details

I. General information

NPI: 1548307713
Provider Name (Legal Business Name): CAMDEN COUNTY SENATE BILL 40 BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 3RD STREET
CAMDENTON MO
65020
US

IV. Provider business mailing address

P.O. BOX 722
CAMDENTON MO
65020
US

V. Phone/Fax

Practice location:
  • Phone: 573-317-9233
  • Fax: 573-317-9332
Mailing address:
  • Phone: 573-317-9233
  • Fax: 573-317-9332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: BOONE CALEB WAGNER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 573-317-9233