Provider Demographics
NPI:1275773376
Name:THE JODY HOUSE ISL COMPANY LLC
Entity Type:Organization
Organization Name:THE JODY HOUSE ISL COMPANY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-465-3654
Mailing Address - Street 1:407 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3368
Mailing Address - Country:US
Mailing Address - Phone:573-465-3654
Mailing Address - Fax:888-858-8055
Practice Address - Street 1:407 E 6TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3368
Practice Address - Country:US
Practice Address - Phone:573-465-3654
Practice Address - Fax:888-858-8055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities