Provider Demographics
NPI:1710699756
Name:MILL CREEK SUPPORTIVE CARE LLC
Entity Type:Organization
Organization Name:MILL CREEK SUPPORTIVE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:DENIECE
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-331-6990
Mailing Address - Street 1:220 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:THAYER
Mailing Address - State:MO
Mailing Address - Zip Code:65791-1511
Mailing Address - Country:US
Mailing Address - Phone:417-264-6161
Mailing Address - Fax:417-264-6162
Practice Address - Street 1:220 MONROE ST
Practice Address - Street 2:
Practice Address - City:THAYER
Practice Address - State:MO
Practice Address - Zip Code:65791-1511
Practice Address - Country:US
Practice Address - Phone:417-264-6161
Practice Address - Fax:417-264-6162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-21
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No385H00000XRespite Care FacilityRespite Care