MEDICARE: PLATTE COUNTY BOARD OF SERVICES FOR THE DEVELOPMENTALLY DISABLED

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	:	1689852238
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLATTE COUNTY BOARD OF SERVICES FOR THE DEVELOPMENTALLY DISABLED

Provider Business Mailing Address
First Line	:	7900 NW 106TH ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64153-2372
Country	:	US
Telephone Number	:	816-891-0990
Fax Number	:	816-891-0937

Provider Business Practice Location Address
First Line	:	4809 NW 67TH ST
Second Line	:	CANTERBURY HOUSE
City	:	KANSAS CITY
State	:	MO
Zip	:	64151-1925
Country	:	US
Telephone Number	:	816-891-0990
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. JANICE TILMAN
Credential	:
Telephone Number	:	816-891-0990

Provider Enumeration Date	:	02/06/2008
Last Update Date	:	02/06/2008

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Directions to “PLATTE COUNTY BOARD OF SERVICES FOR THE DEVELOPMENTALLY DISABLED ” Practice Location

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