Healthcare Provider Details

I. General information

NPI: 1457027419
Provider Name (Legal Business Name): LACEY ANN SKELTON LEVEL 1 MED AIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18941 CR 305A
EMINENCE MO
65466-6268
US

IV. Provider business mailing address

18941 CR 305A
EMINENCE MO
65466-6268
US

V. Phone/Fax

Practice location:
  • Phone: 573-226-5426
  • Fax: 573-226-5426
Mailing address:
  • Phone: 573-226-5426
  • Fax: 573-226-5426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number049124
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: