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General NPI Number Information
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NPI Number | 1841494507
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Entity Type | Organization
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Legal Business Name | MISSOURI BOOTHEEL REGIONAL CONSORTIUM, INC.
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Dates
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Enumeration Date | 06/14/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 46 E STATE HIGHWAY 162
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City | PORTAGEVILLE
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State | MO
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Zip | 63873-9177
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Country | US
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Telephone | 573-379-2020
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Fax | 573-379-3108
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Provider Business Mailing Address
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Address Line | 46 E STATE HIGHWAY 162
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City | PORTAGEVILLE
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State | MO
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Zip | 63873-9177
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Country | US
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Telephone | 573-379-2020
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Fax | 573-379-3108
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Authorized Official
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Title or Position | CEO
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Name | MRS. CYNTHIA GAIL DEAN
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Credential |
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Telephone | 573-379-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 18915361
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License Number State | MO
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