Provider Demographics
NPI:1356462022
Name:PULASKI COUNTY GROUP HOME
Entity Type:Organization
Organization Name:PULASKI COUNTY GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BOBBIE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-736-5603
Mailing Address - Street 1:PO BOX 662
Mailing Address - Street 2:
Mailing Address - City:CROCKER
Mailing Address - State:MO
Mailing Address - Zip Code:65452-0662
Mailing Address - Country:US
Mailing Address - Phone:573-736-5603
Mailing Address - Fax:573-736-2771
Practice Address - Street 1:307 KEETH ROAD
Practice Address - Street 2:
Practice Address - City:CROCKER
Practice Address - State:MO
Practice Address - Zip Code:65452
Practice Address - Country:US
Practice Address - Phone:573-736-5603
Practice Address - Fax:573-736-2771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO853890804Medicaid