Healthcare Provider Details

I. General information

NPI: 1295990208
Provider Name (Legal Business Name): ANNIE'S HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2008
Last Update Date: 07/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107B AMHERST ST
FULTON MO
65251-2373
US

IV. Provider business mailing address

1107B AMHERST ST
FULTON MO
65251-2373
US

V. Phone/Fax

Practice location:
  • Phone: 573-310-9333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY ANN LEE
Title or Position: ADMINISTRATOR
Credential:
Phone: 573-310-9333