Organization · Type 2 NPI

State of Missouri

Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility · Poplar Bluff, MO

NPI number 1598906372 Active

Practice location

2351 Kanell Blvd
Poplar Bluff, MO 63901-4035

Call (573) 840-9374 Map

Mailing address

1706 E Elm St
Jefferson City, MO 65101-4130

Specialties and licenses

Taxonomy	Code	License
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility Primary	320900000X	None listed

Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility: A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with intellectual and/or developmental disabilities.

5 other providers at this address

Other intellectual and/or developmental disabilities community based residential treatment facility providers in Poplar Bluff

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NPI record

NPI: 1598906372
Entity type: Organization (Type 2)
Issued: Mar 9, 2009
Last updated: Sep 3, 2020
Status: Active
Subpart: Yes of State of Missouri

Other names

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Southeast Missouri Residential Services Isl · doing business as
Southeast Missouri Residential Services Isl · doing business as

Authorized official

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

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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 1598906372

State of Missouri's National Provider Identifier is 1598906372, issued on Mar 9, 2009. The primary taxonomy on file is Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility (320900000X), and the practice location is in Poplar Bluff, MO. The record was last updated on Sep 3, 2020.