Provider Demographics
NPI:1649328204
Name:FERNDALE, INC.
Entity type:Organization
Organization Name:FERNDALE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:L
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-265-3344
Mailing Address - Street 1:15650 COUNTY ROAD 2430
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:MO
Mailing Address - Zip Code:65559-8210
Mailing Address - Country:US
Mailing Address - Phone:573-265-3344
Mailing Address - Fax:573-265-1119
Practice Address - Street 1:15650 COUNTY ROAD 2430
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:MO
Practice Address - Zip Code:65559-8210
Practice Address - Country:US
Practice Address - Phone:573-265-3344
Practice Address - Fax:573-265-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO17899078320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities