=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437715679
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAFE SURROUNDINGS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2019
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | COUNTY ROAD AK-544A
-----------------------------------------------------
City | SEYMOUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65746-9314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-683-1808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | RR 2 BOX 2761
-----------------------------------------------------
City | SEYMOUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65746-9314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-683-1808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CAROLYN MARIE MYERS
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 417-683-1808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XE0001X
-----------------------------------------------------
Taxonomy Name | Environmental Modification Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------