=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477874196
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEVELOPMENTAL CONNECTIONS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2010
-----------------------------------------------------
Last Update Date | 06/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1533 E STATE HIGHWAY 76
-----------------------------------------------------
City | BRANSON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65616-7422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-335-4135
-----------------------------------------------------
Fax | 417-334-1316
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1701
-----------------------------------------------------
City | HOLLISTER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65673-1701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-335-4135
-----------------------------------------------------
Fax | 417-334-1316
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. MAX JONES LYTLE
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 417-335-4135
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------