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General NPI Number Information
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NPI Number | 1104079896
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Entity Type | Organization
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Legal Business Name | MARTY ENTERPRISES, INC
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Dates
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Enumeration Date | 10/28/2008
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Last Update Date | 10/28/2008
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Provider Practice Location Address
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Address Line | 800 N PROVIDENCE RD SUITE 104
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City | COLUMBIA
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State | MO
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Zip | 65203-4300
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Country | US
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Telephone | 573-499-3784
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Fax | 573-499-3771
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Provider Business Mailing Address
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Address Line | 800 N PROVIDENCE RD SUITE 104
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City | COLUMBIA
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State | MO
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Zip | 65203-4300
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Country | US
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Telephone | 573-499-3784
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Fax | 573-499-3771
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Authorized Official
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Title or Position | DIRECTOR/SATOP ADMINISTRATOR
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Name | MS. SHELLEY S. RIECKE
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Credential |
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Telephone | 573-499-3784
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 092
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License Number State | MO
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