Provider Demographics
NPI:1104967637
Name:KELLEY L YEOKUM
Entity type:Organization
Organization Name:KELLEY L YEOKUM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:YEOKUM
Authorized Official - Suffix:
Authorized Official - Credentials:MSE
Authorized Official - Phone:816-419-7106
Mailing Address - Street 1:27421 S STATE ROUTE 2
Mailing Address - Street 2:
Mailing Address - City:FREEMAN
Mailing Address - State:MO
Mailing Address - Zip Code:64746-7102
Mailing Address - Country:US
Mailing Address - Phone:816-250-2398
Mailing Address - Fax:816-250-2398
Practice Address - Street 1:27421 S STATE ROUTE 2
Practice Address - Street 2:
Practice Address - City:FREEMAN
Practice Address - State:MO
Practice Address - Zip Code:64746-7102
Practice Address - Country:US
Practice Address - Phone:816-250-2398
Practice Address - Fax:816-250-2398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO62819415320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities