Healthcare Provider Details

I. General information

NPI: 1275773376
Provider Name (Legal Business Name): THE JODY HOUSE ISL COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2009
Last Update Date: 03/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 E 6TH ST
ROLLA MO
65401-3368
US

IV. Provider business mailing address

407 E 6TH ST
ROLLA MO
65401-3368
US

V. Phone/Fax

Practice location:
  • Phone: 573-465-3654
  • Fax: 888-858-8055
Mailing address:
  • Phone: 573-465-3654
  • Fax: 888-858-8055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: CHAD ROBERT LEWIS
Title or Position: DIRECTOR
Credential:
Phone: 573-465-3654