Healthcare Provider Details

I. General information

NPI: 1427612134
Provider Name (Legal Business Name): HOLLAND RESIDENTIAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2019
Last Update Date: 04/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12510 JACKSON AVE
GRANDVIEW MO
64030-1593
US

IV. Provider business mailing address

12510 JACKSON AVE
GRANDVIEW MO
64030-1593
US

V. Phone/Fax

Practice location:
  • Phone: 816-982-9481
  • Fax:
Mailing address:
  • Phone: 816-982-9481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHAWANA JENKINS
Title or Position: EXECUTIVE DIRECTOR
Credential: MPA, MSW
Phone: 816-982-9481