Organization · Type 2 NPI

State of Missouri

Intellectual Disabilities Intermediate Care Facility · Poplar Bluff, MO

NPI number 1124198981 Active

Practice location

2351 Kanell Blvd
Poplar Bluff, MO 63901-4035

Call (573) 840-9370 Map

Fax (573) 840-9373

Mailing address

PO Box 687
Jefferson City, MO 65102-0687

Specialties and licenses

Taxonomy	Code	License
Intellectual Disabilities Intermediate Care Facility Primary	315P00000X	EXEMPT (MO)

Intellectual Disabilities Intermediate Care Facility: An intermediate care facility providing services for individuals with intellectual disabilities.

5 other providers at this address

NPI record

NPI: 1124198981
Entity type: Organization (Type 2)
Issued: Nov 9, 2006
Last updated: Oct 27, 2020
Status: Active
Subpart: Yes of State of Missouri

Other names

<unavail>
Southeast Missouri Residential Services-Poplar Bluff · doing business as
Southeast Missouri Residential Services-Poplar Bluff · doing business as

Authorized official

Molly Jane Boeckmann
Director of Administrative Services
(573) 751-4055

Verify this record

This page mirrors the public NPPES file. For credentialing or billing, confirm it on the official CMS NPI Registry, and check the license with the state board.

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About NPI 1124198981

State of Missouri's National Provider Identifier is 1124198981, issued on Nov 9, 2006. The primary taxonomy on file is Intellectual Disabilities Intermediate Care Facility (315P00000X), and the practice location is in Poplar Bluff, MO. The record was last updated on Oct 27, 2020.