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General NPI Number Information
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NPI Number | 1831248517
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Entity Type | Organization
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Legal Business Name | MASHBURN RESIDENTIAL LEARNING CENTER
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Dates
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Enumeration Date | 01/10/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 807 N BRIARWOOD DR
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City | BOLIVAR
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State | MO
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Zip | 65613-1281
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Country | US
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Telephone | 417-326-6512
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Fax |
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Provider Business Mailing Address
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Address Line | 807 N BRIARWOOD DR
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City | BOLIVAR
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State | MO
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Zip | 65613-1281
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Country | US
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Telephone | 417-326-6512
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LINDA L MASHBURN
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Credential |
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Telephone | 417-326-6512
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 14209362
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License Number State | MO
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