Healthcare Provider Details

I. General information

NPI: 1255974143
Provider Name (Legal Business Name): OWL ADVENTURES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S 3RD ST
HAYTI MO
63851-1617
US

IV. Provider business mailing address

215 S 3RD ST
HAYTI MO
63851-1617
US

V. Phone/Fax

Practice location:
  • Phone: 573-922-7383
  • Fax:
Mailing address:
  • Phone: 573-922-7383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: LARA HUFFMAN
Title or Position: CEO
Credential: M.D.
Phone: 573-922-7383