MEDICARE: PRAIRIE HOME R-V

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	251300000X	Local Education Agency (LEA)

General Provider Information

NPI Number	:	1841683638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRAIRIE HOME R-V

Provider Business Mailing Address
First Line	:	301 HIGHWAY DR # 87
Second Line	:
City	:	PRAIRIE HOME
State	:	MO
Zip	:	65068-2333
Country	:	US
Telephone Number	:	660-841-5296
Fax Number	:	660-841-5513

Provider Business Practice Location Address
First Line	:	301 HIGHWAY DR # 87
Second Line	:
City	:	PRAIRIE HOME
State	:	MO
Zip	:	65068-2333
Country	:	US
Telephone Number	:	660-841-5296
Fax Number	:	660-841-5513

Authorized Official
Title or Position	:	SUPERINTENDENT
Name	:	DR. SPEPHEN BARNES
Credential	:
Telephone Number	:	660-841-5296

Provider Enumeration Date	:	03/18/2015
Last Update Date	:	03/18/2015

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