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General NPI Number Information
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NPI Number | 1104560838
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Entity Type | Organization
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Legal Business Name | MARYS VILLAGE FOUNDATION
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Dates
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Enumeration Date | 04/27/2022
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Last Update Date | 04/27/2022
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Provider Practice Location Address
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Address Line | 3922 N BELT W
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City | BELLEVILLE
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State | IL
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Zip | 62226-5608
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Country | US
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Telephone | 618-974-4807
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Fax |
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Provider Business Mailing Address
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Address Line | 3922 N BELT W
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City | BELLEVILLE
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State | IL
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Zip | 62226-5608
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Country | US
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Telephone | 618-974-4807
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MISS SHANTA DOSS
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Credential | MS
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Telephone | 618-974-4807
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172A00000X
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Taxonomy Name | Driver
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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