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General NPI Number Information
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NPI Number | 1720152077
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Entity Type | Organization
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Legal Business Name | INDEPENDENT LIVING CENTER OF SOUTHEAST MISSOURI, INC.
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Dates
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Enumeration Date | 11/20/2006
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Last Update Date | 09/14/2021
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Provider Practice Location Address
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Address Line | 511 CEDAR ST
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City | POPLAR BLUFF
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State | MO
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Zip | 63901-7301
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Country | US
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Telephone | 573-686-2333
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Fax | 573-686-1641
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Provider Business Mailing Address
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Address Line | 511 CEDAR ST
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City | POPLAR BLUFF
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State | MO
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Zip | 63901-7301
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Country | US
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Telephone | 573-686-2333
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Fax | 573-686-1641
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. JENNIFER BROWN
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Credential |
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Telephone | 573-686-2333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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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 | 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 #3
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State | MO
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