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General NPI Number Information
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NPI Number | 1326372301
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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 | 09/24/2009
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Last Update Date | 10/27/2020
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Provider Practice Location Address
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Address Line | 11 BRADY CIR 2
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City | SAINT LOUIS
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State | MO
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Zip | 63114-1110
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Country | US
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Telephone | 314-340-6701
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Fax | 314-340-6746
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Provider Business Mailing Address
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Address Line | 11 BRADY CIR 2
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City | SAINT LOUIS
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State | MO
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Zip | 63114-1110
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Country | US
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Telephone | 314-340-6701
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Fax | 314-340-6746
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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 | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | E650S000001
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License Number State | MO
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