Provider Demographics
NPI:1528234465
Name:PERRY COUNTY BOARD FOR THE DEVELOPMENTALLY DISABLED
Entity type:Organization
Organization Name:PERRY COUNTY BOARD FOR THE DEVELOPMENTALLY DISABLED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT SENATE BILL 40
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-547-2158
Mailing Address - Street 1:618 INDUSTRIAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-1200
Mailing Address - Country:US
Mailing Address - Phone:573-547-6639
Mailing Address - Fax:573-517-0401
Practice Address - Street 1:618 INDUSTRIAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-1200
Practice Address - Country:US
Practice Address - Phone:573-547-6639
Practice Address - Fax:573-517-0401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
251B0000X251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO159920305Medicaid