Provider Demographics
NPI:1144402488
Name:HOME COURT ADVANTAGE V
Entity Type:Organization
Organization Name:HOME COURT ADVANTAGE V
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCRIMMON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:417-777-6980
Mailing Address - Street 1:972 E 433RD RD
Mailing Address - Street 2:PO BOX 771
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613
Mailing Address - Country:US
Mailing Address - Phone:417-777-6980
Mailing Address - Fax:417-777-6981
Practice Address - Street 1:1211 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2952
Practice Address - Country:US
Practice Address - Phone:417-777-6980
Practice Address - Fax:417-777-6981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities