Healthcare Provider Details

I. General information

NPI: 1629256722
Provider Name (Legal Business Name): TRI-COUNTY GROUP XV, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3230 EMERALD LN STE 400
JEFFERSON CITY MO
65109-3711
US

IV. Provider business mailing address

3010 LYNDON B JOHNSON FWY STE 1100
DALLAS TX
75234-2712
US

V. Phone/Fax

Practice location:
  • Phone: 573-893-8545
  • Fax: 573-893-8540
Mailing address:
  • Phone: 517-768-4373
  • Fax: 903-537-8420

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:

# 1
Identifier851701706
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer
# 2
Identifier851701700
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerMETAL HEALTH

VIII. Authorized Official

Name: KATIE LYNN MONASTIERE
Title or Position: COMPLIANCE AND PRIVACY OFFICER
Credential:
Phone: 517-768-4373