Provider Demographics
NPI:1285057034
Name:ROARK ISL
Entity type:Organization
Organization Name:ROARK ISL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:ROARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-826-0244
Mailing Address - Street 1:27880 HACKBERRY DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-0561
Mailing Address - Country:US
Mailing Address - Phone:660-826-0244
Mailing Address - Fax:660-829-4872
Practice Address - Street 1:219 W 24TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-8303
Practice Address - Country:US
Practice Address - Phone:660-826-0244
Practice Address - Fax:660-829-4872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-30
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCC1-0207-0413320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities