Provider Demographics
NPI:1366564676
Name:CYPRESS CREEK RESIDENTIAL CARE LLC
Entity type:Organization
Organization Name:CYPRESS CREEK RESIDENTIAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-351-1221
Mailing Address - Street 1:546 RIPLEY BB-1
Mailing Address - Street 2:
Mailing Address - City:FAIRDEALING
Mailing Address - State:MO
Mailing Address - Zip Code:63939-8003
Mailing Address - Country:US
Mailing Address - Phone:573-351-1221
Mailing Address - Fax:
Practice Address - Street 1:546 RIPLEY BB-1
Practice Address - Street 2:
Practice Address - City:FAIRDEALING
Practice Address - State:MO
Practice Address - Zip Code:63939-8003
Practice Address - Country:US
Practice Address - Phone:573-351-1221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251C00000X, 385H00000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO853295210Medicaid