Healthcare Provider Details

I. General information

NPI: 1871627448
Provider Name (Legal Business Name): LAKE OF THE OZARKS DEVELOPMENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 08/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1867 SOUTH STATE HIGHWAY 5
CAMDENTON MO
65020
US

IV. Provider business mailing address

PO BOX 753
CAMDENTON MO
65020-0753
US

V. Phone/Fax

Practice location:
  • Phone: 573-346-4574
  • Fax: 573-346-7426
Mailing address:
  • Phone: 573-346-4574
  • Fax: 573-346-7426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number15428899
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number15428899
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number15428899
License Number StateMO

VIII. Authorized Official

Name: MS. MARILYN LEIGH MARTIN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 573-346-4574