Provider Demographics
NPI:1760855431
Name:CAMBRIDGE OF BRANSON LLC
Entity Type:Organization
Organization Name:CAMBRIDGE OF BRANSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-544-0630
Mailing Address - Street 1:4675 N GRETNA RD STE 201
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-7583
Mailing Address - Country:US
Mailing Address - Phone:417-339-4232
Mailing Address - Fax:417-334-5087
Practice Address - Street 1:4470 N GRETNA RD
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-7202
Practice Address - Country:US
Practice Address - Phone:417-544-0630
Practice Address - Fax:417-544-0671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-03
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1291261QA0600X
261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1760855431Medicaid