Provider Demographics
NPI:1831319177
Name:RUDROFF ISL, LLC
Entity Type:Organization
Organization Name:RUDROFF ISL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:RUDROFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-897-4700
Mailing Address - Street 1:1205 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LINN
Mailing Address - State:MO
Mailing Address - Zip Code:65051-2502
Mailing Address - Country:US
Mailing Address - Phone:573-897-4700
Mailing Address - Fax:573-897-0256
Practice Address - Street 1:1207 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LINN
Practice Address - State:MO
Practice Address - Zip Code:65051
Practice Address - Country:US
Practice Address - Phone:573-897-4700
Practice Address - Fax:573-897-0256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities