Provider Demographics
NPI:1982978169
Name:RANDOLPH COUNTY DEVELOPMENTAL DISABILITY SERVICES
Entity type:Organization
Organization Name:RANDOLPH COUNTY DEVELOPMENTAL DISABILITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:BREID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-269-8875
Mailing Address - Street 1:PO BOX 1008
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-0975
Mailing Address - Country:US
Mailing Address - Phone:660-269-8875
Mailing Address - Fax:660-269-9621
Practice Address - Street 1:101 W COATES ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-1521
Practice Address - Country:US
Practice Address - Phone:660-269-8875
Practice Address - Fax:660-269-9621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2012-09-04
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
MO159041201Medicaid