1093981052 NPI number — PROGRESSIVE ALTERNATIVE LIVING, INC.

Table of content: (NPI 1093981052)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093981052 NPI number — PROGRESSIVE ALTERNATIVE LIVING, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESSIVE ALTERNATIVE LIVING, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PAL
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093981052
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
410 W BROADWAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGGINSVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64037-1947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
660-584-2199
Provider Business Mailing Address Fax Number:
660-584-3199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 W BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGGINSVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64037-1947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-584-2199
Provider Business Practice Location Address Fax Number:
660-584-3199
Provider Enumeration Date:
04/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MARR
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
660-584-2199

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  8530834180 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 853083400 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 853083418 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com