Healthcare Provider Details

I. General information

NPI: 1649057241
Provider Name (Legal Business Name): IDD ARK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 W WORLEY ST
COLUMBIA MO
65203-1037
US

IV. Provider business mailing address

PO BOX 597
WENTZVILLE MO
63385-0597
US

V. Phone/Fax

Practice location:
  • Phone: 573-207-2070
  • Fax: 573-375-8467
Mailing address:
  • Phone: 573-975-3602
  • Fax: 573-375-8467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: BRITTANI GARDNER-EVANS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 573-975-3602