Healthcare Provider Details

I. General information

NPI: 1497834667
Provider Name (Legal Business Name): INDEPENDENT LIVING RESOURCE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 01/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 W TRUMAN BLVD STE D
JEFFERSON CITY MO
65109-6125
US

IV. Provider business mailing address

PO BOX 6787
JEFFERSON CITY MO
65102-6787
US

V. Phone/Fax

Practice location:
  • Phone: 573-556-0400
  • Fax: 573-556-0402
Mailing address:
  • Phone: 573-556-0400
  • Fax: 573-556-0402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. STEPHANIE COX
Title or Position: EXECUTIVE DIRECTOR
Credential: MSW
Phone: 573-556-0400