MEDICARE: JAYS RESIDENTIAL LLC - TREVIS HOUSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility		MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639296270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAYS RESIDENTIAL LLC - TREVIS HOUSE

Provider Business Mailing Address
First Line	:	12731 RICHMOND AVE
Second Line	:
City	:	GRANDVIEW
State	:	MO
Zip	:	64030-2160
Country	:	US
Telephone Number	:	816-456-6461
Fax Number	:	816-965-0131

Provider Business Practice Location Address
First Line	:	12731 RICHMOND AVE
Second Line	:
City	:	GRANDVIEW
State	:	MO
Zip	:	64030-2160
Country	:	US
Telephone Number	:	816-456-6461
Fax Number	:	816-965-0131

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JASON LEE RUDOLPH
Credential	:	BS
Telephone Number	:	816-456-6461

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	08/22/2020

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Directions to “JAYS RESIDENTIAL LLC - TREVIS HOUSE ” Practice Location

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