Healthcare Provider Details

I. General information

NPI: 1881181170
Provider Name (Legal Business Name): IRONTON RESIDENTIAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S KNOB ST
IRONTON MO
63650-1501
US

IV. Provider business mailing address

PO BOX 272
FARMINGTON MO
63640-0272
US

V. Phone/Fax

Practice location:
  • Phone: 573-546-3080
  • Fax:
Mailing address:
  • Phone: 573-330-3760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: KAREN EILEEN VEACH
Title or Position: OWNER
Credential:
Phone: 573-330-3760