Healthcare Provider Details

I. General information

NPI: 1124155916
Provider Name (Legal Business Name): CHARITON VALLEY ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 E LAHARPE ST
KIRKSVILLE MO
63501-3981
US

IV. Provider business mailing address

1905 S HIGH ST
KIRKSVILLE MO
63501-4764
US

V. Phone/Fax

Practice location:
  • Phone: 660-665-1111
  • Fax:
Mailing address:
  • Phone: 660-665-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MR. TERRY COMBS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 660-665-1111