=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740052299
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETTY LOU WALLACE RECOVERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2023
-----------------------------------------------------
Last Update Date | 12/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13013 STATE LINE RD
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-599-7382
-----------------------------------------------------
Fax | 816-599-7510
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13340 HOLMES RD
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-599-7382
-----------------------------------------------------
Fax | 816-599-7510
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER/CEO
-----------------------------------------------------
Name | KEVIN O'GRADY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 816-599-7382
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------