Provider Demographics
NPI:1790940989
Name:BAREFOOTBOY LLC
Entity Type:Organization
Organization Name:BAREFOOTBOY LLC
Other - Org Name:OAKBROOK RESIDENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAJAB
Authorized Official - Middle Name:TONGWA
Authorized Official - Last Name:ECHESSA
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:417-207-1680
Mailing Address - Street 1:723 S SCENIC AVE
Mailing Address - Street 2:723 S.SCENIC
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-5042
Mailing Address - Country:US
Mailing Address - Phone:417-864-6200
Mailing Address - Fax:417-864-4413
Practice Address - Street 1:723 S SCENIC AVE
Practice Address - Street 2:723 S.SCENIC
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-5042
Practice Address - Country:US
Practice Address - Phone:417-864-6200
Practice Address - Fax:417-864-4413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO035394320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266758408Medicaid