Provider Demographics
NPI:1174862577
Name:COUNCIL OF CHURCHES OF THE OZARKS
Entity Type:Organization
Organization Name:COUNCIL OF CHURCHES OF THE OZARKS
Other - Org Name:DAYBREAK ADULT DAY CARE / ELDERCARE TRANSIT SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:STRUCKHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:REV
Authorized Official - Phone:417-862-3586
Mailing Address - Street 1:PO BOX 3947
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-3947
Mailing Address - Country:US
Mailing Address - Phone:417-862-3586
Mailing Address - Fax:417-862-2129
Practice Address - Street 1:1461 E SEMINOLE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2431
Practice Address - Country:US
Practice Address - Phone:417-881-0133
Practice Address - Fax:417-882-3739
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNCIL OF CHURCHES OF THE OZARKS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-05
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1063261QA0600X, 385HR2060X
MOER019913016261QM0850X, 320900000X
MOU182232013343800000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No343800000XTransportation ServicesSecured Medical Transport (VAN)
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO291869501Medicaid