Provider Demographics
NPI:1093981052
Name:PROGRESSIVE ALTERNATIVE LIVING, INC.
Entity Type:Organization
Organization Name:PROGRESSIVE ALTERNATIVE LIVING, INC.
Other - Org Name:PAL
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-584-2199
Mailing Address - Street 1:410 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HIGGINSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64037-1947
Mailing Address - Country:US
Mailing Address - Phone:660-584-2199
Mailing Address - Fax:660-584-3199
Practice Address - Street 1:410 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HIGGINSVILLE
Practice Address - State:MO
Practice Address - Zip Code:64037-1947
Practice Address - Country:US
Practice Address - Phone:660-584-2199
Practice Address - Fax:660-584-3199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO8530834180315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO853083400Medicaid
MO853083418Medicaid