=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790806545
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PULASKI COUNTRY GROUP HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 307 KEETH ROAD
-----------------------------------------------------
City | CROCKER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-736-5603
-----------------------------------------------------
Fax | 573-736-2771
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 662
-----------------------------------------------------
City | CROCKER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65452-0662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-736-5603
-----------------------------------------------------
Fax | 573-736-2771
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. BOBBIE JEAN MORRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-736-5603
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------