Provider Demographics
NPI:1366582827
Name:MISSOURI SCHOOLS FOR THE SEVERELY DISABLED
Entity type:Organization
Organization Name:MISSOURI SCHOOLS FOR THE SEVERELY DISABLED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ARCHIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DERBOVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-751-4427
Mailing Address - Street 1:205 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-2901
Mailing Address - Country:US
Mailing Address - Phone:573-751-0408
Mailing Address - Fax:573-522-9242
Practice Address - Street 1:205 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-2901
Practice Address - Country:US
Practice Address - Phone:573-751-0408
Practice Address - Fax:573-751-0276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504852302Medicaid