Healthcare Provider Details

I. General information

NPI: 1679602049
Provider Name (Legal Business Name): BOARD OF EXPANDED SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2007
Last Update Date: 10/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 N MAIN ST
CARROLLTON MO
64633-1933
US

IV. Provider business mailing address

PO BOX 455
CARROLLTON MO
64633-0455
US

V. Phone/Fax

Practice location:
  • Phone: 660-542-1401
  • Fax:
Mailing address:
  • Phone: 660-542-1401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number852991900
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number852991900
License Number StateMO

VIII. Authorized Official

Name: RUTH A THURLO
Title or Position: EXECUTIVE SECRETARY
Credential:
Phone: 660-542-1401