MEDICARE: ALICE SUE CONRAD

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	8001661	MO

General Provider Information

NPI Number	:	1922128487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALICE SUE CONRAD

Provider Business Mailing Address
First Line	:	1407 SAINT ANDREW ST
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203-2327
Country	:	US
Telephone Number	:	573-875-6751
Fax Number	:	573-442-2086

Provider Business Practice Location Address
First Line	:	1407 SAINT ANDREW ST
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203-2327
Country	:	US
Telephone Number	:	573-875-6751
Fax Number	:	573-442-2086

Authorized Official
Title or Position	:	OWNER
Name	:	MS. ALICE SUE CONRAD
Credential	:
Telephone Number	:	573-875-6751

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	06/13/2008

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Directions to “ALICE SUE CONRAD ” Practice Location

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