Provider Demographics
NPI:1093221749
Name:LETTUCE DREAM
Entity Type:Organization
Organization Name:LETTUCE DREAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:D
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-224-2203
Mailing Address - Street 1:PO BOX 272
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-0272
Mailing Address - Country:US
Mailing Address - Phone:660-224-2203
Mailing Address - Fax:660-224-2203
Practice Address - Street 1:1623 E 2ND ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-1959
Practice Address - Country:US
Practice Address - Phone:660-224-2203
Practice Address - Fax:660-224-2203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251C00000X
347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No347C00000XTransportation ServicesPrivate Vehicle