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General NPI Number Information
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NPI Number | 1285227397
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Entity Type | Organization
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Legal Business Name | DIANA'S BOARDING HOME 2 INC
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Dates
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Enumeration Date | 02/19/2021
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Last Update Date | 02/19/2021
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Provider Practice Location Address
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Address Line | 4677 STATE HWY M
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City | MARBLE HILL
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State | MO
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Zip | 63764-9408
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Country | US
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Telephone | 573-238-3344
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Fax | 573-238-3361
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Provider Business Mailing Address
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Address Line | HC 64 BOX 4677
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City | MARBLE HILL
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State | MO
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Zip | 63764-9408
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Country | US
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Telephone | 573-238-3344
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Fax | 573-238-3361
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | MR. TERRY DUSTIN WAGNER
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Credential |
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Telephone | 573-238-3344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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