Provider Demographics
NPI:1558753640
Name:BUNKER RESIDENTIAL HOME DBA
Entity Type:Organization
Organization Name:BUNKER RESIDENTIAL HOME DBA
Other - Org Name:REYNOLDS COUNTY EXECUTIVE BOARD OF DEVELOPMENTAL DISABILITIES SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANIS
Authorized Official - Middle Name:F
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-689-2213
Mailing Address - Street 1:PO BOX 276 500 CULLER AVE
Mailing Address - Street 2:
Mailing Address - City:BUNKER
Mailing Address - State:MO
Mailing Address - Zip Code:63629
Mailing Address - Country:US
Mailing Address - Phone:573-689-2213
Mailing Address - Fax:573-689-2214
Practice Address - Street 1:500 CULLER AVE
Practice Address - Street 2:
Practice Address - City:BUNKER
Practice Address - State:MO
Practice Address - Zip Code:63629
Practice Address - Country:US
Practice Address - Phone:573-689-1392
Practice Address - Fax:573-689-1397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042886310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility