=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861557183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOOTHEEL AREA INDEPENDENT LIVING SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 719 TEACO RD
-----------------------------------------------------
City | KENNETT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63857-3741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-888-0002
-----------------------------------------------------
Fax | 573-888-0708
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 326 719 TEACO ROAD
-----------------------------------------------------
City | KENNETT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63857-0326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-888-0002
-----------------------------------------------------
Fax | 573-888-0708
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. TIM B SHAW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-888-0002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 01
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------