Healthcare Provider Details

I. General information

NPI: 1194933499
Provider Name (Legal Business Name): STATE OF MISSOURI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2312 LEMAY FERRY RD
SAINT LOUIS MO
63125-3127
US

IV. Provider business mailing address

1706 E ELM ST
JEFFERSON CITY MO
65101-4130
US

V. Phone/Fax

Practice location:
  • Phone: 314-894-5400
  • Fax:
Mailing address:
  • Phone: 573-751-3398
  • Fax: 573-526-4560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

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