Provider Demographics
NPI:1154452563
Name:ROARK I.S.L.
Entity Type:Organization
Organization Name:ROARK I.S.L.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TREVIS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ROARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-826-3666
Mailing Address - Street 1:219 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-8303
Mailing Address - Country:US
Mailing Address - Phone:660-826-3666
Mailing Address - Fax:660-827-9854
Practice Address - Street 1:219 W 24TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-8303
Practice Address - Country:US
Practice Address - Phone:660-826-3666
Practice Address - Fax:660-827-9854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
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