Provider Demographics
NPI:1902029325
Name:WYATT HOUSE
Entity Type:Organization
Organization Name:WYATT HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:THROCKMORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-537-8858
Mailing Address - Street 1:707 WYATT AVE
Mailing Address - Street 2:PO BOX 459
Mailing Address - City:GOLDEN CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64748-8300
Mailing Address - Country:US
Mailing Address - Phone:417-537-8858
Mailing Address - Fax:417-537-4203
Practice Address - Street 1:707 WYATT AVE
Practice Address - Street 2:
Practice Address - City:GOLDEN CITY
Practice Address - State:MO
Practice Address - Zip Code:64748-8300
Practice Address - Country:US
Practice Address - Phone:417-537-8858
Practice Address - Fax:417-537-4203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO5687-9292320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities