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General NPI Number Information
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NPI Number | 1710053780
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Entity Type | Organization
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Legal Business Name | STATE OF MISSOURI
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Dates
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Enumeration Date | 11/28/2006
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Last Update Date | 09/03/2020
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Provider Practice Location Address
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Address Line | 111 N 7TH ST WAINWRIGHT STATE OFFICE BLDG - 6TH FLOOR
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City | SAINT LOUIS
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State | MO
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Zip | 63101-2100
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Country | US
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Telephone | 314-244-8800
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Fax | 314-244-8941
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Provider Business Mailing Address
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Address Line | 1706 E ELM ST
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City | JEFFERSON CITY
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State | MO
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Zip | 65101-4130
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Country | US
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Telephone | 573-751-3398
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Fax | 573-526-4560
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Authorized Official
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Title or Position | DIRECTOR OF ADMINISTRATIVE SERVICES
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Name | MOLLY JANE BOECKMANN
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Credential |
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Telephone | 573-751-4055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | EXEMPT
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License Number State | MO
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