=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104071455
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDERSON ISL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2008
-----------------------------------------------------
Last Update Date | 11/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 503 E CLARK ST
-----------------------------------------------------
City | WARRENSBURG
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64093-2405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-221-2118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 503 E CLARK ST
-----------------------------------------------------
City | WARRENSBURG
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64093-2405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-221-2118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | JANE ANDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 660-221-2118
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------