Healthcare Provider Details

I. General information

NPI: 1093221749
Provider Name (Legal Business Name): LETTUCE DREAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2017
Last Update Date: 12/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1623 E 2ND ST
MARYVILLE MO
64468-1959
US

IV. Provider business mailing address

PO BOX 272
MARYVILLE MO
64468-0272
US

V. Phone/Fax

Practice location:
  • Phone: 660-224-2203
  • Fax: 660-224-2203
Mailing address:
  • Phone: 660-224-2203
  • Fax: 660-224-2203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: HEATHER D THORNTON
Title or Position: PROGRAM MANAGER
Credential:
Phone: 660-224-2203