Provider Demographics
NPI:1720157803
Name:BOYS & GIRLS TOWN OF MISSOURI
Entity Type:Organization
Organization Name:BOYS & GIRLS TOWN OF MISSOURI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-865-1646
Mailing Address - Street 1:4696 N FARM ROAD 129
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-6229
Mailing Address - Country:US
Mailing Address - Phone:417-425-6273
Mailing Address - Fax:
Practice Address - Street 1:1212 W LOMBARD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2720
Practice Address - Country:US
Practice Address - Phone:417-865-1646
Practice Address - Fax:417-866-1483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001021788322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children