Healthcare Provider Details

I. General information

NPI: 1467570085
Provider Name (Legal Business Name): MCWILLIAMS MANOR, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3439 S WESTWOOD BLVD
POPLAR BLUFF MO
63901-8670
US

IV. Provider business mailing address

3439 S WESTWOOD BLVD
POPLAR BLUFF MO
63901-8670
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-4035
  • Fax: 573-785-4035
Mailing address:
  • Phone: 573-785-4035
  • Fax: 573-785-4035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number7048378
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number7048378
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number7048378
License Number StateMO

VIII. Authorized Official

Name: MR. RICHARD MCWILLIAMS
Title or Position: OWNER
Credential:
Phone: 573-785-4035