Healthcare Provider Details

I. General information

NPI: 1174862577
Provider Name (Legal Business Name): COUNCIL OF CHURCHES OF THE OZARKS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1461 E SEMINOLE ST
SPRINGFIELD MO
65804-2431
US

IV. Provider business mailing address

PO BOX 3947
SPRINGFIELD MO
65808-3947
US

V. Phone/Fax

Practice location:
  • Phone: 417-881-0133
  • Fax: 417-882-3739
Mailing address:
  • Phone: 417-862-3586
  • Fax: 417-862-2129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberER019913016
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberER019913016
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License NumberU182232013
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberU182232013
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number1063
License Number StateMO
# 6
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number1063
License Number StateMO

VIII. Authorized Official

Name: MR. MARK WILLIAM STRUCKHOFF
Title or Position: EXECUTIVE DIRECTOR
Credential: REV.
Phone: 417-862-3586