=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164799417
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOME CARE ISL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2011
-----------------------------------------------------
Last Update Date | 11/30/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1018 JOHNSON STREET
-----------------------------------------------------
City | FREDERICKTOWN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63645-0467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-631-1456
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 467 1018 JOHNSON STREET
-----------------------------------------------------
City | FREDERICKTOWN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63645-0467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | SUSAN STOTZ
-----------------------------------------------------
Credential | RN, QDDP
-----------------------------------------------------
Telephone | 573-631-1456
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------