Provider Demographics
NPI:1780701557
Name:SOUTHERN MISSOURI SUPPORTED LIVING
Entity type:Organization
Organization Name:SOUTHERN MISSOURI SUPPORTED LIVING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-447-0905
Mailing Address - Street 1:4909 COCHERO CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-9758
Mailing Address - Country:US
Mailing Address - Phone:573-447-0905
Mailing Address - Fax:
Practice Address - Street 1:RR 2 BOX 2610
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:MO
Practice Address - Zip Code:65606-9633
Practice Address - Country:US
Practice Address - Phone:417-778-1685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO320900000X, 385H00000X, 251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered385H00000XRespite Care FacilityRespite Care
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services