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General NPI Number Information
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NPI Number | 1700545670
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Entity Type | Organization
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Legal Business Name | TRI-COUNTY COMMUNITY INDIVIDUALIZED SUPPORTED LIVING, LLC
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Dates
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Enumeration Date | 12/08/2021
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Last Update Date | 12/08/2021
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Provider Practice Location Address
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Address Line | 46 E STATE HIGHWAY 162
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City | PORTAGEVILLE
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State | MO
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Zip | 63873-9177
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Country | US
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Telephone | 573-391-8031
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Fax | 573-391-8050
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Provider Business Mailing Address
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Address Line | 46 E STATE HIGHWAY 162
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City | PORTAGEVILLE
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State | MO
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Zip | 63873-9177
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Country | US
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Telephone | 573-391-8031
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Fax | 573-391-8050
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | LADONNA JEAN WILLIAMS
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Credential | DNP
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Telephone | 573-391-8031
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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