Provider Demographics
NPI:1093844722
Name:NORTHWEST MISSOURI SUPPORTIVE SERVICES
Entity Type:Organization
Organization Name:NORTHWEST MISSOURI SUPPORTIVE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:WEATHERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-827-1254
Mailing Address - Street 1:PO BOX 222
Mailing Address - Street 2:401 SOUTH STANBERRY STREET
Mailing Address - City:STANBERRY
Mailing Address - State:MO
Mailing Address - Zip Code:64489-0222
Mailing Address - Country:US
Mailing Address - Phone:660-783-2842
Mailing Address - Fax:
Practice Address - Street 1:308 SOUTH PROSPECT
Practice Address - Street 2:
Practice Address - City:STANBERRY
Practice Address - State:MO
Practice Address - Zip Code:64489-0222
Practice Address - Country:US
Practice Address - Phone:660-783-2464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities