Provider Demographics
NPI:1598764110
Name:COLLEGE SKYLINE CENTER LLC
Entity Type:Organization
Organization Name:COLLEGE SKYLINE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:EDDINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-782-1443
Mailing Address - Street 1:1230 N DUQUESNE RD
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-1509
Mailing Address - Country:US
Mailing Address - Phone:417-782-1443
Mailing Address - Fax:417-782-3240
Practice Address - Street 1:1230 N DUQUESNE RD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-1509
Practice Address - Country:US
Practice Address - Phone:417-782-1443
Practice Address - Fax:417-782-3240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 2084P0800X
MO14301709106H00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507593408Medicaid
MO0000015177Medicare NSC
MO1598764110Medicare NSC