1871627448 NPI number — LAKE OF THE OZARKS DEVELOPMENTAL CENTER

Table of content: (NPI 1629585674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871627448 NPI number — LAKE OF THE OZARKS DEVELOPMENTAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE OF THE OZARKS DEVELOPMENTAL CENTER
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:
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:
1871627448
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 753
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMDENTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65020-0753
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-346-4574
Provider Business Mailing Address Fax Number:
573-346-7426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1867 SOUTH STATE HIGHWAY 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMDENTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-346-4574
Provider Business Practice Location Address Fax Number:
573-346-7426
Provider Enumeration Date:
03/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
MARILYN
Authorized Official Middle Name:
LEIGH
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
573-346-4574

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , with the licence number:  15428899 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 320900000X , with the licence number: 15428899 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 343900000X , with the licence number: 15428899 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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