1700901816 NPI number — JODY HOUSE LLC

Table of content: (NPI 1700901816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700901816 NPI number — JODY HOUSE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JODY HOUSE LLC
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:
Provider Other Organization Name Type Code:
6
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:
1700901816
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
407 E 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROLLA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65401-3368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-578-2979
Provider Business Mailing Address Fax Number:
573-364-4778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 NORTH WALNUT
Provider Second Line Business Practice Location Address:
2608 BROOK
Provider Business Practice Location Address City Name:
ROLLA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-578-2979
Provider Business Practice Location Address Fax Number:
572-364-4778
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RUCK
Authorized Official First Name:
RUTH LEE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
573-578-2979

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , with the licence number:  265068694 , 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: 856095401 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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