Healthcare Provider Details

I. General information

NPI: 1407926140
Provider Name (Legal Business Name): STATE OF MISSOURI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 FAIRGROUNDS RD
ROLLA MO
65401-2909
US

IV. Provider business mailing address

1706 E ELM ST
JEFFERSON CITY MO
65101-4130
US

V. Phone/Fax

Practice location:
  • Phone: 573-368-2200
  • Fax: 573-368-2206
Mailing address:
  • Phone: 573-751-3398
  • Fax: 573-526-4560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberEXEMPT
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier151792900
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: MOLLY JANE BOECKMANN
Title or Position: DIRECTOR OF ADMINISTRATIVE SERVICES
Credential:
Phone: 573-751-4055