Provider Demographics
NPI:1104958040
Name:CALLAWAY COUNTY SPECIAL SERVFICES
Entity type:Organization
Organization Name:CALLAWAY COUNTY SPECIAL SERVFICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-642-1792
Mailing Address - Street 1:911 S BUSINESS 54
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-1406
Mailing Address - Country:US
Mailing Address - Phone:573-642-1792
Mailing Address - Fax:
Practice Address - Street 1:226 MAPLE ST
Practice Address - Street 2:
Practice Address - City:NEW BLOOMFIELD
Practice Address - State:MO
Practice Address - Zip Code:65063-1594
Practice Address - Country:US
Practice Address - Phone:573-491-3858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CALLAWAY COUNTY SPECIAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-09
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO853013803Medicaid