Healthcare Provider Details

I. General information

NPI: 1063565901
Provider Name (Legal Business Name): JEFFERSON C-123 SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37614 US HIGHWAY 136
CONCEPTION JUNCTION MO
64434-8109
US

IV. Provider business mailing address

37614 US HIGHWAY 136
CONCEPTION JUNCTION MO
64434-8109
US

V. Phone/Fax

Practice location:
  • Phone: 660-944-2316
  • Fax: 660-944-2315
Mailing address:
  • Phone: 660-944-2316
  • Fax: 660-944-2315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number506127802
License Number StateMO

VIII. Authorized Official

Name: MR. ROBERT P. DOWIS
Title or Position: SUPERINTENDENT
Credential:
Phone: 660-944-2316