# STATE OF MISSOURI

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** STATE OF MISSOURI
- **Other names:** Bellefontaine Habilitation Center
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1710931167
- **Legal business name:** STATE OF MISSOURI
- **Authorized official:** MOLLY JANE BOECKMANN (DIRECTOR OF ADMINISTRATIVE SERVICES)
- **Authorized official phone:** (573) 751-4055

## Contact information

- **Practice address:** 10695 BELLEFONTAINE RD, SAINT LOUIS, MO 63137-2315
- **Practice address phone:** (314) 340-6000
- **Practice address fax:** (314) 340-6199
- **Mailing address:** 1706 E ELM ST, JEFFERSON CITY, MO 65101-4130
- **Mailing address phone:** (573) 751-3398
- **Mailing address fax:** (573) 526-4560

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | — | — |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | — | Yes |
| 2084P0800X | Psychiatry Physician | — | — | — |

## Other

- **Enumeration date:** 05/20/2006
- **Last updated:** 10/27/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 501500102 | — | MO |
| 01 | — | CG4952 | MEDICARE RAILROAD | MO |