Provider Demographics
NPI:1891063400
Name:INDEPEDENCE CENTER OF STE. GENEVIEVE COUNTY LLC
Entity type:Organization
Organization Name:INDEPEDENCE CENTER OF STE. GENEVIEVE COUNTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:ZOELLNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-883-3330
Mailing Address - Street 1:21530 HWY 32
Mailing Address - Street 2:SUITE B
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-8813
Mailing Address - Country:US
Mailing Address - Phone:573-883-3330
Mailing Address - Fax:573-883-3332
Practice Address - Street 1:21530 HWY 32
Practice Address - Street 2:SUITE B
Practice Address - City:STE GENEVIEVE
Practice Address - State:MO
Practice Address - Zip Code:63670-8813
Practice Address - Country:US
Practice Address - Phone:573-883-3330
Practice Address - Fax:573-883-3332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities