Provider Demographics
NPI:1972632883
Name:RUTH JENSEN VILLAGE RESIDENTIAL SERVICES, INC. ISL II
Entity type:Organization
Organization Name:RUTH JENSEN VILLAGE RESIDENTIAL SERVICES, INC. ISL II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BURT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-324-3580
Mailing Address - Street 1:5 INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:MO
Mailing Address - Zip Code:63334-2436
Mailing Address - Country:US
Mailing Address - Phone:573-324-3580
Mailing Address - Fax:573-324-6323
Practice Address - Street 1:5 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:MO
Practice Address - Zip Code:63334-2436
Practice Address - Country:US
Practice Address - Phone:573-324-3580
Practice Address - Fax:573-324-6323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1422-9250320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities