Provider Demographics
NPI:1699135939
Name:PETTIS COUNTY BOARD OF SERVICES FOR THE DEVELOPMENTALLY DISABLED
Entity type:Organization
Organization Name:PETTIS COUNTY BOARD OF SERVICES FOR THE DEVELOPMENTALLY DISABLED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-826-4400
Mailing Address - Street 1:1500 EWING DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2396
Mailing Address - Country:US
Mailing Address - Phone:660-826-4400
Mailing Address - Fax:866-495-6424
Practice Address - Street 1:1500 EWING DR
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2396
Practice Address - Country:US
Practice Address - Phone:660-826-4400
Practice Address - Fax:866-495-6424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management