Provider Demographics
NPI:1750638656
Name:TRI-COUNTY CENTER FOR INDEPENDENT LIVING
Entity Type:Organization
Organization Name:TRI-COUNTY CENTER FOR INDEPENDENT LIVING
Other - Org Name:HOME OUTREACH FOR PERSONAL EXCELLENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-368-5933
Mailing Address - Street 1:1420 E STATE ROUTE 72
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3988
Mailing Address - Country:US
Mailing Address - Phone:573-368-5933
Mailing Address - Fax:573-368-5991
Practice Address - Street 1:1420 E STATE ROUTE 72
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3988
Practice Address - Country:US
Practice Address - Phone:573-368-5933
Practice Address - Fax:573-368-5991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-09
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO276236205Medicaid