MEDICARE: FERNDALE, INC.

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	17899078	MO

General Provider Information

NPI Number	:	1649328204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FERNDALE, INC.

Provider Business Mailing Address
First Line	:	15650 COUNTY ROAD 2430
Second Line	:
City	:	SAINT JAMES
State	:	MO
Zip	:	65559-8210
Country	:	US
Telephone Number	:	573-265-3344
Fax Number	:	573-265-1119

Provider Business Practice Location Address
First Line	:	15650 COUNTY ROAD 2430
Second Line	:
City	:	SAINT JAMES
State	:	MO
Zip	:	65559-8210
Country	:	US
Telephone Number	:	573-265-3344
Fax Number	:	573-265-1119

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. JANET L. DOUGLAS
Credential	:
Telephone Number	:	573-265-3344

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	06/16/2008

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Directions to “FERNDALE, INC. ” Practice Location

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