Provider Demographics
NPI:1396865713
Name:PONY BIRD INCORPORATED
Entity Type:Organization
Organization Name:PONY BIRD INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DALLAS
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, MAHSM
Authorized Official - Phone:636-931-5818
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:MAPAVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63065-0190
Mailing Address - Country:US
Mailing Address - Phone:636-931-5818
Mailing Address - Fax:
Practice Address - Street 1:#1 PONY BIRD LANE
Practice Address - Street 2:
Practice Address - City:MAPAVILLE
Practice Address - State:MO
Practice Address - Zip Code:63065-0190
Practice Address - Country:US
Practice Address - Phone:636-931-5818
Practice Address - Fax:636-931-3518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1351-8421320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities