Healthcare Provider Details

I. General information

NPI: 1891624409
Provider Name (Legal Business Name): PRIME SUPPORTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 WALTON HEATH CT
COLUMBIA MO
65201-5822
US

IV. Provider business mailing address

117 WALTON HEATH CT
COLUMBIA MO
65201-5822
US

V. Phone/Fax

Practice location:
  • Phone: 619-451-1491
  • Fax:
Mailing address:
  • Phone: 619-451-1491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MURAMA ALOYS
Title or Position: OWNER
Credential:
Phone: 619-451-1491