Healthcare Provider Details

I. General information

NPI: 1891063400
Provider Name (Legal Business Name): INDEPEDENCE CENTER OF STE. GENEVIEVE COUNTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2011
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21530 HWY 32 SUITE B
STE GENEVIEVE MO
63670-8813
US

IV. Provider business mailing address

21530 HWY 32 SUITE B
STE GENEVIEVE MO
63670-8813
US

V. Phone/Fax

Practice location:
  • Phone: 573-883-3330
  • Fax: 573-883-3332
Mailing address:
  • Phone: 573-883-3330
  • Fax: 573-883-3332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANDREA KAY ZOELLNER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 573-883-3330