Provider Demographics
NPI:1295014470
Name:SOUTHEAST MISSOURI STATE UNIVERSITY
Entity Type:Organization
Organization Name:SOUTHEAST MISSOURI STATE UNIVERSITY
Other - Org Name:HORIZONS ENRICHMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:BSPA
Authorized Official - Phone:573-290-5115
Mailing Address - Street 1:2100 THEMIS ST STE 103C
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-5124
Mailing Address - Country:US
Mailing Address - Phone:573-290-5115
Mailing Address - Fax:573-290-5142
Practice Address - Street 1:2100 THEMIS ST STE 103C
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5124
Practice Address - Country:US
Practice Address - Phone:573-290-5115
Practice Address - Fax:573-290-5142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-05
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1780753640Medicaid