Organization
STATE OF MISSOURI
Active
Parent organization
STATE OF MISSOURI
Other names
Bellefontaine Habilitation Center
Organization subpart
Yes
Provider details
NPI number
Legal business name
STATE OF MISSOURI
Authorized official
MOLLY JANE BOECKMANN (DIRECTOR OF ADMINISTRATIVE SERVICES)
(573) 751-4055
Entity
Organization
Contact information
Practice address
10695 BELLEFONTAINE RD, SAINT LOUIS, MO 63137-2315
(314) 340-6000
(314) 340-6199
Mailing address
1706 E ELM ST, JEFFERSON CITY, MO 65101-4130
(573) 751-3398
(573) 526-4560
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
—
208100000X
Physical Medicine & Rehabilitation Physician
Primary
—
—
2084P0800X
Psychiatry Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
501500102
—
MO
01
—
CG4952
MEDICARE RAILROAD
MO
Enumeration date
05/20/2006
Last updated
10/27/2020
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