MEDICARE: MULBERRY STREET LLC

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	:	1902099013
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MULBERRY STREET LLC

Provider Business Mailing Address
First Line	:	1519 SW STATE ROUTE 7
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64014-3944
Country	:	US
Telephone Number	:	816-224-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1519 SW STATE ROUTE 7
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64014-3944
Country	:	US
Telephone Number	:	816-224-2000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. DIANE MARIE MACK
Credential	:
Telephone Number	:	816-224-2000

Provider Enumeration Date	:	08/22/2007
Last Update Date	:	01/07/2013

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Directions to “MULBERRY STREET LLC ” Practice Location

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