Healthcare Provider Details

I. General information

NPI: 1003030727
Provider Name (Legal Business Name): WYATT HOUSE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 WYATT AVE
GOLDEN CITY MO
64748-8300
US

IV. Provider business mailing address

707 WYATT AVE
GOLDEN CITY MO
64748-8300
US

V. Phone/Fax

Practice location:
  • Phone: 417-537-4200
  • Fax:
Mailing address:
  • Phone: 417-537-4200
  • Fax: 417-537-4200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number5687-9292
License Number StateMO

VIII. Authorized Official

Name: PAUL D THROCKMORTON
Title or Position: CEO
Credential:
Phone: 417-537-4200