NPIMap

Organization Active NPI

Southeast Missouri Residential Services

  • Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
  • Poplar Bluff, MO
National Provider Identifier
1568601482
Registry record updated Oct 15, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityTaxonomy code 320900000X
Legal business name
SOUTHEAST MISSOURI RESIDENTIAL SERVICES
Practice address
2351 Kanell Blvd
Poplar Bluff, MO 63901-4035
Phone
(573) 840-9300
Fax
(573) 840-9373
NPI assigned
Feb 17, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 15, 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 and/or Developmental Disabilities Community Based Residential Treatment Facility 320900000X Primary

Addresses

Primary practice location

2351 Kanell Blvd
Poplar Bluff, MO 63901-4035

Mailing address

2351 Kanell Blvd
Poplar Bluff, MO 63901-4035
Phone (573) 840-9300

Other identifiers 1

IdentifierTypeStateIssuer
856407804MedicaidMO

National Provider Directory

National Provider Directory
Tax ID family
Southwest Missouri Psy104 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

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

View all 24

Locations

2200 Bergquist Dr
Ste 1
Wilford Hall, TX 78236
Phone (210) 292-5336

NPI Registry JSON

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

{
    "created_epoch": "1234828800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1602720000000",
    "number": "1568601482",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2351 KANELL BLVD",
            "city": "POPLAR BLUFF",
            "state": "MO",
            "postal_code": "639014035",
            "telephone_number": "573-840-9300",
            "fax_number": "573-840-9373"
        },
        {
            "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": "573-840-9300",
            "fax_number": "573-840-9373"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEAST MISSOURI RESIDENTIAL SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-02-17",
        "last_updated": "2020-10-15",
        "certification_date": "2020-10-15",
        "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": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "856407804",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Poplar Bluff, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 15, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.