Provider Demographics
NPI:1922526417
Name:HARD KNOCKS LLC
Entity Type:Organization
Organization Name:HARD KNOCKS LLC
Other - Org Name:PINE VALLEY RCF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-760-8601
Mailing Address - Street 1:614 WALMART DR STE 108
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-3315
Mailing Address - Country:US
Mailing Address - Phone:314-479-7516
Mailing Address - Fax:
Practice Address - Street 1:3381 1ST ST
Practice Address - Street 2:
Practice Address - City:DOE RUN
Practice Address - State:MO
Practice Address - Zip Code:63637-3155
Practice Address - Country:US
Practice Address - Phone:573-760-8601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOEL-0996-INIT320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO=========Medicaid