Healthcare Provider Details

I. General information

NPI: 1720115579
Provider Name (Legal Business Name): TRI-COUNTY CENTER FOR INDEPENDENT LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 E STATE ROUTE 72
ROLLA MO
65401-3988
US

IV. Provider business mailing address

1420 E STATE ROUTE 72
ROLLA MO
65401-3988
US

V. Phone/Fax

Practice location:
  • Phone: 573-368-5933
  • Fax: 573-368-5991
Mailing address:
  • Phone: 573-368-5933
  • Fax: 573-368-5991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier266236207
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: MR. DOUGLAS WILLIAMS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 573-368-5933