Provider Demographics
NPI:1710031422
Name:STANBERRY INDEPENDENT LIVING
Entity Type:Organization
Organization Name:STANBERRY INDEPENDENT LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-783-2093
Mailing Address - Street 1:1319 NORTH ALANTHUS ST.
Mailing Address - Street 2:
Mailing Address - City:STANBERRY
Mailing Address - State:MO
Mailing Address - Zip Code:64489-0160
Mailing Address - Country:US
Mailing Address - Phone:660-783-2093
Mailing Address - Fax:660-783-2013
Practice Address - Street 1:1319 NORTH ALANTHUS ST.
Practice Address - Street 2:
Practice Address - City:STANBERRY
Practice Address - State:MO
Practice Address - Zip Code:64489-0160
Practice Address - Country:US
Practice Address - Phone:660-783-2093
Practice Address - Fax:660-783-2013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
Not Answered347C00000XTransportation ServicesPrivate Vehicle
Not Answered376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
Not Answered385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMW01150Medicare ID - Type Unspecified