Provider Demographics
NPI:1700901816
Name:JODY HOUSE LLC
Entity Type:Organization
Organization Name:JODY HOUSE LLC
Other - Org Name:VISIONS ISL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-578-2979
Mailing Address - Street 1:407 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3368
Mailing Address - Country:US
Mailing Address - Phone:573-578-2979
Mailing Address - Fax:573-364-4778
Practice Address - Street 1:602 NORTH WALNUT
Practice Address - Street 2:2608 BROOK
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-578-2979
Practice Address - Fax:572-364-4778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO265068694320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO856095401Medicaid