Healthcare Provider Details

I. General information

NPI: 1992028112
Provider Name (Legal Business Name): HILDA FUWELL'S RESIDENTIAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 SOUTH ONE MILE ROAD
DEXTER MO
63841
US

IV. Provider business mailing address

17382 STATE HIGHWAY 25
DEXTER MO
63841-9710
US

V. Phone/Fax

Practice location:
  • Phone: 573-614-4191
  • Fax: 573-568-2314
Mailing address:
  • Phone: 573-568-2056
  • Fax: 573-568-2314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TERESA A ALLEN
Title or Position: OWNER
Credential:
Phone: 573-568-2056