Healthcare Provider Details

I. General information

NPI: 1598142069
Provider Name (Legal Business Name): CLINTON COUNTY SENATE BILL 40 BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2015
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 ELM ST
LATHROP MO
64465
US

IV. Provider business mailing address

PO BOX 397
LATHROP MO
64465-0397
US

V. Phone/Fax

Practice location:
  • Phone: 816-528-3846
  • Fax:
Mailing address:
  • Phone: 816-528-3846
  • Fax:

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: MS. SHARON NONE GRAYSON
Title or Position: PRESIDENT OF THE BOARD
Credential:
Phone: 816-585-7411