Provider Demographics
NPI:1215056437
Name:BROOKSIDE CASA
Entity type:Organization
Organization Name:BROOKSIDE CASA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENSIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SPOTILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-378-2266
Mailing Address - Street 1:17858 BROOKSIDE RD
Mailing Address - Street 2:
Mailing Address - City:BARNETT
Mailing Address - State:MO
Mailing Address - Zip Code:65011-3023
Mailing Address - Country:US
Mailing Address - Phone:573-378-2266
Mailing Address - Fax:573-378-2267
Practice Address - Street 1:17858 BROOKSIDE RD
Practice Address - Street 2:
Practice Address - City:BARNETT
Practice Address - State:MO
Practice Address - Zip Code:65011-3023
Practice Address - Country:US
Practice Address - Phone:573-378-2266
Practice Address - Fax:573-378-2267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO856254107Medicaid