Provider Demographics
NPI:1265654628
Name:BRACKEN HOMES
Entity Type:Organization
Organization Name:BRACKEN HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPRV QMRP
Authorized Official - Prefix:MS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-507-8997
Mailing Address - Street 1:PO BOX 454
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64012
Mailing Address - Country:US
Mailing Address - Phone:816-507-8997
Mailing Address - Fax:
Practice Address - Street 1:8108 BEL RAY DR
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012
Practice Address - Country:US
Practice Address - Phone:816-507-8997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO8000161320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities