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Organization

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Active
Organization subpart
No

Provider details

NPI number
Authorized official
TABATHA JO PETERSON (OWNER/PARTNER)
(660) 235-0076
Entity
Organization

Contact information

Practice address
720 N WILLOW ST, STANBERRY, MO 64489-1057
(660) 235-0076
Mailing address
720 N WILLOW ST, STANBERRY, MO 64489-1057
(660) 235-0076

Taxonomy

Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
10816254
MO

Other

Enumeration date
06/11/2008
Last updated
06/11/2008
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