NPIMap

Organization Active NPI

State of Missouri

Doing business as Southeast Missouri Residential Services-Poplar Bluff

  • Intellectual Disabilities Intermediate Care Facility
  • Poplar Bluff, MO
National Provider Identifier
1124198981
Registry record updated Oct 27, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
EXEMPT Issued in MO
Legal business name
STATE OF MISSOURI
Doing business as
Southeast Missouri Residential Services-Poplar Bluff
Practice address
2351 Kanell Blvd
Poplar Bluff, MO 63901-4035
Phone
(573) 840-9370
Fax
(573) 840-9373
NPI assigned
Nov 9, 2006
Last updated
Oct 27, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
STATE OF MISSOURIAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 27, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Molly Jane Boeckmann
Title
Director of Administrative Services
Phone
(573) 751-4055

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X EXEMPT MO Primary

Addresses

Primary practice location

2351 Kanell Blvd
Poplar Bluff, MO 63901-4035

Mailing address

PO Box 687
Jefferson City, MO 65102-0687
Phone (573) 751-3398

Other identifiers 1

IdentifierTypeStateIssuer
051793107MedicaidMO

Other names 1

  • Southeast Missouri Residential Services-Poplar Bluff Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124198981. Details of each certification follow.

  • CCN 26G026 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 26G026

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
SEMORS-Poplar Bluff Site
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Jun 6, 1986
Last certification
Apr 10, 2025
Beds
56
Ownership / control type
State
Most recent change of ownership
Dec 1, 2012
Facility address
2351 Kanell Blvd.
Poplar Bluff, MO 63901

National Provider Directory

National Provider Directory
Tax ID family
Missouri Tuberculosis Lab104 organizations share this tax ID, including this one
Part of
Missouri Tuberculosis Lab

Organizations with this tax ID in the same state 20

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 20

Locations

2351 Kanell Blvd
Poplar Bluff, MO 63901
Phone (573) 840-9300

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1163030400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1603756800000",
    "number": "1124198981",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 687",
            "city": "JEFFERSON CITY",
            "state": "MO",
            "postal_code": "651020687",
            "telephone_number": "573-751-3398",
            "fax_number": "573-526-4560"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2351 KANELL BLVD",
            "city": "POPLAR BLUFF",
            "state": "MO",
            "postal_code": "639014035",
            "telephone_number": "573-840-9370",
            "fax_number": "573-840-9373"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATE OF MISSOURI",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "STATE OF MISSOURI",
        "enumeration_date": "2006-11-09",
        "last_updated": "2020-10-27",
        "certification_date": "2020-10-27",
        "status": "A",
        "authorized_official_last_name": "BOECKMANN",
        "authorized_official_first_name": "MOLLY",
        "authorized_official_middle_name": "JANE",
        "authorized_official_title_or_position": "DIRECTOR OF ADMINISTRATIVE SERVICES",
        "authorized_official_telephone_number": "573-751-4055"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "MO",
            "license": "EXEMPT",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "051793107",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southeast Missouri Residential Services-Poplar Bluff",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Southeast Missouri Residential Services-Poplar Bluff",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Poplar Bluff, MO

Sources for this page

Verify at the official NPI Registry.