Provider Demographics
NPI:1326372301
Name:STATE OF MISSOURI
Entity Type:Organization
Organization Name:STATE OF MISSOURI
Other - Org Name:SLDDTC - 2 BRADY CIRCLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATIVE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:BOECKMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-751-4055
Mailing Address - Street 1:11 BRADY CIR
Mailing Address - Street 2:2
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-1110
Mailing Address - Country:US
Mailing Address - Phone:314-340-6701
Mailing Address - Fax:314-340-6746
Practice Address - Street 1:11 BRADY CIR
Practice Address - Street 2:2
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63114-1110
Practice Address - Country:US
Practice Address - Phone:314-340-6701
Practice Address - Fax:314-340-6746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-24
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOE650S000001320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities