Healthcare Provider Details

I. General information

NPI: 1902251507
Provider Name (Legal Business Name): MINERAL AREA COMMUNITY PSYCHIATRIC REHABILITATION CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 05/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W PINE ST
FARMINGTON MO
63640-1426
US

IV. Provider business mailing address

560 W PINE ST P O BOX 510
FARMINGTON MO
63640-1426
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-2899
  • Fax: 573-756-4105
Mailing address:
  • Phone: 573-756-2899
  • Fax: 573-756-4105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number2162
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number2162
License Number StateMO

VIII. Authorized Official

Name: MRS. VICKY L WINICK
Title or Position: PRESIDENT EXECUTIVE DIRECTOR
Credential: LMSW
Phone: 573-756-2899