Provider Demographics
NPI:1689798456
Name:DEVELOPMENTAL DISABILITIES ASSISTANCE BOARD OF MONTGOMERY COUNTY
Entity Type:Organization
Organization Name:DEVELOPMENTAL DISABILITIES ASSISTANCE BOARD OF MONTGOMERY COUNTY
Other - Org Name:MONTGOMERY COUNTY SENATE BILL 40 BOARD
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-564-5045
Mailing Address - Street 1:230 E NORMAN ST
Mailing Address - Street 2:P.O. BOX 63
Mailing Address - City:MONTGOMERY CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63361-1427
Mailing Address - Country:US
Mailing Address - Phone:573-564-5045
Mailing Address - Fax:573-564-3662
Practice Address - Street 1:513 KAY LN
Practice Address - Street 2:
Practice Address - City:MONTGOMERY CITY
Practice Address - State:MO
Practice Address - Zip Code:63361-2311
Practice Address - Country:US
Practice Address - Phone:573-564-2778
Practice Address - Fax:573-564-3662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO7070268320900000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies