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State of Missouri

Organization Active NPI Intellectual Disabilities Intermediate Care Facility · Overland, MO

NPI 1164630463 · NPPES record last updated Oct 27, 2020

Key facts

NPI
1164630463
Entity type
Organization (NPI type 2)
Primary specialty
Intellectual Disabilities Intermediate Care Facility 315P00000X
Legal business name
STATE OF MISSOURI
Practice address
11 Brady Cir
Overland, MO 63114-1110
Phone
(314) 428-8470
NPI assigned
May 18, 2007
Organization subpart
Yes
Parent organization (as reported)
STATE OF MISSOURI

Authorized official

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

Corporate family (same tax ID) 24

Organizations that report the same tax identification number in the National Provider Directory.

National Provider Directory

Tax ID family
Southwest Missouri Psy (104 organizations share this tax ID)
Part of
Southwest Missouri Psy

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X Yes

Addresses

Primary practice location

11 Brady Cir
Overland, MO 63114-1110

Mailing address

1706 E Elm St
Jefferson City, MO 65101-4130
Phone (573) 751-3398

Other identifiers

IdentifierTypeStateIssuer
052361904MedicaidMO

Other names

  • North West Habilitation Center Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Oct 27, 2020.

{
    "created_epoch": "1179446400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1603756800000",
    "number": "1164630463",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1706 E ELM ST",
            "city": "JEFFERSON CITY",
            "state": "MO",
            "postal_code": "651014130",
            "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": "11 BRADY CIR",
            "city": "OVERLAND",
            "state": "MO",
            "postal_code": "631141110",
            "telephone_number": "314-428-8470"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATE OF MISSOURI",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "STATE OF MISSOURI",
        "enumeration_date": "2007-05-18",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "052361904",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "North West Habilitation Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "North West Habilitation Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Overland, MO

All providers in Overland, MO · Intellectual Disabilities Intermediate Care Facility in Missouri

Sources for this page

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