Provider Demographics
NPI:1467570085
Name:MCWILLIAMS MANOR, INCORPORATED
Entity Type:Organization
Organization Name:MCWILLIAMS MANOR, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MCWILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-785-4035
Mailing Address - Street 1:3439 S WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-8670
Mailing Address - Country:US
Mailing Address - Phone:573-785-4035
Mailing Address - Fax:573-785-4035
Practice Address - Street 1:3439 S WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8670
Practice Address - Country:US
Practice Address - Phone:573-785-4035
Practice Address - Fax:573-785-4035
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCWILLIAMS MANOR, INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-26
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO7048378251C00000X, 320900000X, 385H00000X
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