Provider Demographics
NPI:1699808766
Name:MCWILLIAMS MANOR, INCORPORATED
Entity Type:Organization
Organization Name:MCWILLIAMS MANOR, INCORPORATED
Other - Org Name:DBA MCWILLIAMS MANOR ISL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WESTOVER-MCWILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MRN
Authorized Official - Phone:573-727-9760
Mailing Address - Street 1:3439 S WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-8670
Mailing Address - Country:US
Mailing Address - Phone:573-727-9760
Mailing Address - Fax:573-727-9760
Practice Address - Street 1:3439 S WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8670
Practice Address - Country:US
Practice Address - Phone:573-727-9760
Practice Address - Fax:573-727-9760
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCWILLIAMS MANOR, INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-14
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO8001561320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO858524713Medicaid