Provider Demographics
NPI:1093977365
Name:APPLEWOOD LANE CORPORATION
Entity Type:Organization
Organization Name:APPLEWOOD LANE CORPORATION
Other - Org Name:BROOKWOOD GROUP HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-722-4416
Mailing Address - Street 1:27 HOPPER TRL
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:MO
Mailing Address - Zip Code:65767-9234
Mailing Address - Country:US
Mailing Address - Phone:417-722-4416
Mailing Address - Fax:417-722-4417
Practice Address - Street 1:27 HOPPER TRL
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:MO
Practice Address - Zip Code:65767-9234
Practice Address - Country:US
Practice Address - Phone:417-722-4416
Practice Address - Fax:417-722-4417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1471 10370315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities