Healthcare Provider Details

I. General information

NPI: 1508882259
Provider Name (Legal Business Name): SOUTHWEST CENTER FOR INDEPENDENT LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 W CAMBRIDGE ST
SPRINGFIELD MO
65807-3726
US

IV. Provider business mailing address

1450 W CAMBRIDGE ST
SPRINGFIELD MO
65807-3726
US

V. Phone/Fax

Practice location:
  • Phone: 417-886-1188
  • Fax: 417-886-3619
Mailing address:
  • Phone: 417-886-1188
  • Fax: 417-886-3619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: SHANNON MARIE PORTER
Title or Position: CEO
Credential:
Phone: 417-886-1188