Provider Demographics
NPI:1104454669
Name:MISSOURI SPROUT MC 1 LLC
Entity type:Organization
Organization Name:MISSOURI SPROUT MC 1 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YURY
Authorized Official - Middle Name:
Authorized Official - Last Name:YAKUBCHYK
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:816-307-1677
Mailing Address - Street 1:1828 WALNUT ST FL 3
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-1835
Mailing Address - Country:US
Mailing Address - Phone:816-307-1677
Mailing Address - Fax:
Practice Address - Street 1:1828 WALNUT ST FL 3
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-1835
Practice Address - Country:US
Practice Address - Phone:816-307-1677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-31
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty