Healthcare Provider Details

I. General information

NPI: 1285227397
Provider Name (Legal Business Name): DIANA'S BOARDING HOME 2 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2021
Last Update Date: 02/19/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4677 STATE HWY M
MARBLE HILL MO
63764-9408
US

IV. Provider business mailing address

HC 64 BOX 4677
MARBLE HILL MO
63764-9408
US

V. Phone/Fax

Practice location:
  • Phone: 573-238-3344
  • Fax: 573-238-3361
Mailing address:
  • Phone: 573-238-3344
  • Fax: 573-238-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. TERRY DUSTIN WAGNER
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 573-238-3344