Healthcare Provider Details

I. General information

NPI: 1902067184
Provider Name (Legal Business Name): BOYS & GIRLS TOWN OF MISSOURI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4304 S BEARFIELD RD
COLUMBIA MO
65201-9557
US

IV. Provider business mailing address

PO BOX 189
SAINT JAMES MO
65559-0189
US

V. Phone/Fax

Practice location:
  • Phone: 573-874-8686
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number2000163689
License Number StateMO

VIII. Authorized Official

Name: VINCE HILLYER
Title or Position: PRESIDENT
Credential:
Phone: 573-265-3251