=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649049081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMALLTOWN OPPORTUNITIES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2023
-----------------------------------------------------
Last Update Date | 12/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1087 UPPER SECOND CREEK RD
-----------------------------------------------------
City | HAZARD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41701-9527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-216-4940
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1087 UPPER SECOND CREEK RD
-----------------------------------------------------
City | HAZARD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41701-9527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-216-4940
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | ROSE MARIE SHIELDS
-----------------------------------------------------
Credential | BS
-----------------------------------------------------
Telephone | 606-216-4940
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------