Healthcare Provider Details

I. General information

NPI: 1144932567
Provider Name (Legal Business Name): MISSOURI GIRLS TOWN FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2022
Last Update Date: 12/23/2022
Certification Date: 12/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8548 JADE ROAD
KINGDOM CITY MO
65262-0059
US

IV. Provider business mailing address

P.O. BOX 86
KINGDOM CITY MO
65262
US

V. Phone/Fax

Practice location:
  • Phone: 573-642-5345
  • Fax: 573-642-5162
Mailing address:
  • Phone: 573-642-5345
  • Fax: 573-642-5162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
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: MIRIAM BURCH
Title or Position: BILLING CLERK
Credential:
Phone: 573-642-5345