Healthcare Provider Details

I. General information

NPI: 1710031422
Provider Name (Legal Business Name): STANBERRY INDEPENDENT LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 NORTH ALANTHUS ST.
STANBERRY MO
64489-0160
US

IV. Provider business mailing address

1319 NORTH ALANTHUS ST.
STANBERRY MO
64489-0160
US

V. Phone/Fax

Practice location:
  • Phone: 660-783-2093
  • Fax: 660-783-2013
Mailing address:
  • Phone: 660-783-2093
  • Fax: 660-783-2013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: TOM MILLER
Title or Position: MANAGER
Credential:
Phone: 660-783-2093