Provider Demographics
NPI:1689842858
Name:BEACONWAY III, LLC
Entity Type:Organization
Organization Name:BEACONWAY III, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-229-0175
Mailing Address - Street 1:441 NORTH DR
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-3309
Mailing Address - Country:US
Mailing Address - Phone:660-229-0175
Mailing Address - Fax:660-831-1189
Practice Address - Street 1:441 NORTH DR
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-3309
Practice Address - Country:US
Practice Address - Phone:660-229-0175
Practice Address - Fax:660-831-1189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities