Provider Demographics
NPI:1962547646
Name:CRITTENTON
Entity type:Organization
Organization Name:CRITTENTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:STARON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-765-6600
Mailing Address - Street 1:10918 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64134-4108
Mailing Address - Country:US
Mailing Address - Phone:816-765-6600
Mailing Address - Fax:
Practice Address - Street 1:10918 ELM AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64134-4108
Practice Address - Country:US
Practice Address - Phone:816-765-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRITTENTON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-21
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO852443605Medicaid