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General NPI Number Information
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NPI Number | 1023292802
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Entity Type | Organization
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Legal Business Name | MADISON COUNTY COUNCIL FOR DEVELOPMENTALLY DISABLED, INC.
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Dates
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Enumeration Date | 12/28/2007
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Last Update Date | 12/28/2007
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Provider Practice Location Address
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Address Line | 610 S CHAMBER DR
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City | FREDERICKTOWN
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State | MO
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Zip | 63645-1742
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Country | US
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Telephone | 573-783-3770
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Fax | 573-783-5051
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Provider Business Mailing Address
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Address Line | PO BOX 325
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City | FREDERICKTOWN
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State | MO
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Zip | 63645-0325
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Country | US
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Telephone | 573-756-8365
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Fax | 573-783-5051
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. CLYDE AVERY CLIFTON
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Credential |
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Telephone | 573-783-3770
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State | MO
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