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General NPI Number Information
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NPI Number | 1316017056
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Entity Type | Organization
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Legal Business Name | STATE OF MISSOURI
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 10/20/2020
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Provider Practice Location Address
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Address Line | 112 PLAZA DR
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City | SIKESTON
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State | MO
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Zip | 63801-5137
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Country | US
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Telephone | 573-472-5300
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Fax | 573-472-5308
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Provider Business Mailing Address
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Address Line | 1706 E ELM ST
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City | JEFFERSON CITY
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State | MO
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Zip | 65101-4130
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Country | US
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Telephone | 573-751-3398
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Fax | 573-526-4560
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Authorized Official
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Title or Position | DIRECTOR OF ADMINISTRATIVE SERVICES
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Name | MOLLY JANE BOECKMANN
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Credential |
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Telephone | 573-751-4055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | EXEMPT
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License Number State | MO
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