=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396567061
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HABY PEACE AT HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2024
-----------------------------------------------------
Last Update Date | 12/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3830 S COUNTRY WOODS RD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-9510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-825-5024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3830 S COUNTRY WOODS RD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-9510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-825-5024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. HADJE ACHTA BOUKARI NAYA
-----------------------------------------------------
Credential | MASTERS OF EDUCATION
-----------------------------------------------------
Telephone | 573-825-5024
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------