Provider Demographics
NPI:1295867521
Name:INDEPENDENT LIVING CENTER OF SOUTHEAST MISSOURI
Entity Type:Organization
Organization Name:INDEPENDENT LIVING CENTER OF SOUTHEAST MISSOURI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-686-2333
Mailing Address - Street 1:511 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-7301
Mailing Address - Country:US
Mailing Address - Phone:573-686-2333
Mailing Address - Fax:573-686-1641
Practice Address - Street 1:511 CEDAR ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-7301
Practice Address - Country:US
Practice Address - Phone:573-686-2333
Practice Address - Fax:573-686-1641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251B00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO286211701Medicaid