Healthcare Provider Details

I. General information

NPI: 1861540510
Provider Name (Legal Business Name): HILDA FUWELLS RESIDENTIAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17382 STATE HIGHWAY 25
DEXTER MO
63841-9710
US

IV. Provider business mailing address

17382 STATE HIGHWAY 25
DEXTER MO
63841-9710
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number031747
License Number StateMO

VIII. Authorized Official

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