=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396941381
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENT COUNTY DEVELOPMENTAL DISABILITIES BOARD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2007
-----------------------------------------------------
Last Update Date | 09/10/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 S. MAIN ST.
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-729-4738
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 702
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65560-0702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-729-4738
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | SANDRA F HOGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-729-4738
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------