Organization
CYPRESS CREEK RESIDENTIAL CARE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. TRACI WAGNER (OWNER)
(573) 351-1221
Entity
Organization
Contact information
Practice address
546 RIPLEY BB-1, FAIRDEALING, MO 63939-8003
(573) 351-1221
Mailing address
546 RIPLEY BB-1, FAIRDEALING, MO 63939-8003
(573) 351-1221
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
—
MO
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
MO
385H00000X
Respite Care
—
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
853295210
—
MO
Enumeration date
04/06/2007
Last updated
10/17/2024
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