=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053450643
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRECKENRIDGE R-I SCHOOL DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 07/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 W COLFAX ST
-----------------------------------------------------
City | BRECKENRIDGE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64625-9608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-544-5715
-----------------------------------------------------
Fax | 660-644-5710
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 W COLFAX ST
-----------------------------------------------------
City | BRECKENRIDGE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64625-9608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-544-5715
-----------------------------------------------------
Fax | 660-644-5710
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DISTRICT COORDINATOR
-----------------------------------------------------
Name | KIMBRA MULLENIX
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 660-644-5715
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------