Healthcare Provider Details

I. General information

NPI: 1952738510
Provider Name (Legal Business Name): OUTREACH SUPPORT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 11/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5014 ROUTE D
RUSSELLVILLE MO
65074-2244
US

IV. Provider business mailing address

5014 ROUTE D
RUSSELLVILLE MO
65074-2244
US

V. Phone/Fax

Practice location:
  • Phone: 573-268-1367
  • Fax:
Mailing address:
  • Phone: 573-268-1367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberLC1334934
License Number StateMO

VIII. Authorized Official

Name: TAMMY KAY TEEL
Title or Position: EXECUTIVE DIRECTOR
Credential: RN
Phone: 573-268-1367