Provider Demographics
NPI:1083073498
Name:DILLAHUNT ENTERPRISES, LLC
Entity Type:Organization
Organization Name:DILLAHUNT ENTERPRISES, LLC
Other - Org Name:DILLAHUNT ISL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:DILLAHUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-445-4408
Mailing Address - Street 1:4300 ROYAL ABERDEEN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-4810
Mailing Address - Country:US
Mailing Address - Phone:573-445-4408
Mailing Address - Fax:573-445-4408
Practice Address - Street 1:4300 ROYAL ABERDEEN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4810
Practice Address - Country:US
Practice Address - Phone:573-445-4408
Practice Address - Fax:573-445-4408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-12
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO093669315P00000X
320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities