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General NPI Number Information
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NPI Number | 1619914538
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Entity Type | Organization
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Legal Business Name | INDEPENDENT LIVING CENTER OF MID-MISSOURI INC.
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Dates
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Enumeration Date | 05/31/2006
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Last Update Date | 03/22/2022
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Provider Practice Location Address
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Address Line | 1401 HATHMAN PL
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City | COLUMBIA
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State | MO
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Zip | 65201-5552
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Country | US
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Telephone | 573-874-1646
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Fax | 573-874-3564
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Provider Business Mailing Address
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Address Line | 1401 HATHMAN PL
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City | COLUMBIA
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State | MO
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Zip | 65201-5552
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Country | US
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Telephone | 573-874-1646
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Fax | 573-874-3564
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. PATRICK LEE
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Credential |
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Telephone | 573-874-1646
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3747P1801X
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Taxonomy Name | Personal Care Attendant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251X00000X
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Taxonomy Name | Supports Brokerage Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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