Healthcare Provider Details

I. General information

NPI: 1679606008
Provider Name (Legal Business Name): CENTER FOR DEVELOPMENTALLY DISABLED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W 39TH ST
KANSAS CITY MO
64111-3880
US

IV. Provider business mailing address

1010 W 39TH ST
KANSAS CITY MO
64111-3880
US

V. Phone/Fax

Practice location:
  • Phone: 816-531-0045
  • Fax: 816-756-5612
Mailing address:
  • Phone: 816-531-0045
  • Fax: 816-756-5612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JIM J JOHNSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 816-531-0045