MEDICARE: MARTHA JEAN PALAZZO

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1639365315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA JEAN PALAZZO

Provider Business Mailing Address
First Line	:	2205 ROSE DR
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65202-3223
Country	:	US
Telephone Number	:	573-447-0263
Fax Number	:

Provider Business Practice Location Address
First Line	:	2205 ROSE DR
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65202-3223
Country	:	US
Telephone Number	:	573-447-0263
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2007
Last Update Date	:	09/17/2007

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