Provider Demographics
NPI:1285227397
Name:DIANA'S BOARDING HOME 2 INC
Entity Type:Organization
Organization Name:DIANA'S BOARDING HOME 2 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:DUSTIN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-238-3344
Mailing Address - Street 1:HC 64 BOX 4677
Mailing Address - Street 2:
Mailing Address - City:MARBLE HILL
Mailing Address - State:MO
Mailing Address - Zip Code:63764-9408
Mailing Address - Country:US
Mailing Address - Phone:573-238-3344
Mailing Address - Fax:573-238-3361
Practice Address - Street 1:4677 STATE HWY M
Practice Address - Street 2:
Practice Address - City:MARBLE HILL
Practice Address - State:MO
Practice Address - Zip Code:63764-9408
Practice Address - Country:US
Practice Address - Phone:573-238-3344
Practice Address - Fax:573-238-3361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness