Healthcare Provider Details

I. General information

NPI: 1922077932
Provider Name (Legal Business Name): SCOTT GREENING CENTER FOR YOUTH DEPENDENCY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 E 20TH ST
JOPLIN MO
64804-0925
US

IV. Provider business mailing address

PO BOX 2187 1315 E. 20TH STREET
JOPLIN MO
64803-2187
US

V. Phone/Fax

Practice location:
  • Phone: 417-623-1990
  • Fax: 417-623-9931
Mailing address:
  • Phone: 417-623-1990
  • Fax: 417-623-9931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number3097-7878
License Number StateMO

VIII. Authorized Official

Name: MRS. LESLIE HOUSE
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 417-623-1990