Provider Demographics
NPI:1811108343
Name:TRI-COUNTY CENTER FOR INDEPENDENT LIVING
Entity type:Organization
Organization Name:TRI-COUNTY CENTER FOR INDEPENDENT LIVING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/ RN SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:573-368-5933
Mailing Address - Street 1:1406 EAST STATE ROUTE 72
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401
Mailing Address - Country:US
Mailing Address - Phone:573-368-5933
Mailing Address - Fax:573-368-5991
Practice Address - Street 1:1406 EAST STATE ROUTE 72
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-368-5933
Practice Address - Fax:573-368-5991
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-COUNTY CENTER FOR INDEPENDENT LIVI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-25
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO286236203Medicaid