Healthcare Provider Details

I. General information

NPI: 1942323738
Provider Name (Legal Business Name): JAMAICA COTTAGE ISL II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31360 AQUA VITA RD
GRAVOIS MILLS MO
65037-4762
US

IV. Provider business mailing address

31360 AQUA VITA RD
GRAVOIS MILLS MO
65037-4762
US

V. Phone/Fax

Practice location:
  • Phone: 573-372-6122
  • Fax:
Mailing address:
  • Phone: 573-372-6122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number1623-8179
License Number StateMO

VIII. Authorized Official

Name: MS. PATRICIA F SCOTT
Title or Position: PRESIDENT
Credential:
Phone: 573-372-6122