Provider Demographics
NPI:1275686776
Name:ASSOCIATION OF GROUP HOMES FOR NODAWAY COUNTY, INC.
Entity Type:Organization
Organization Name:ASSOCIATION OF GROUP HOMES FOR NODAWAY COUNTY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:CARRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1660-582-7113
Mailing Address - Street 1:122 EAST LIEBER ST
Mailing Address - Street 2:PO BOX 454
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-0454
Mailing Address - Country:US
Mailing Address - Phone:660-582-7113
Mailing Address - Fax:660-582-3493
Practice Address - Street 1:749 W TORRANCE ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2516
Practice Address - Country:US
Practice Address - Phone:660-582-7113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO5473-7088320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities