Provider Demographics
NPI:1689839763
Name:RENOVO BOYS ACADEMY
Entity Type:Organization
Organization Name:RENOVO BOYS ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ALLRED
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:573-384-5755
Mailing Address - Street 1:240 MAGEE ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-3182
Mailing Address - Country:US
Mailing Address - Phone:573-384-5755
Mailing Address - Fax:573-384-5756
Practice Address - Street 1:308 BUCK CREEK RD
Practice Address - Street 2:
Practice Address - City:SILEX
Practice Address - State:MO
Practice Address - Zip Code:63377-2116
Practice Address - Country:US
Practice Address - Phone:573-384-5755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROFICIO MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002109748322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children