Provider Demographics
NPI:1982878112
Name:GARDEN OF SUCCESS DBA: SUPPORT PROFESSIONALS
Entity Type:Organization
Organization Name:GARDEN OF SUCCESS DBA: SUPPORT PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:WANETTA
Authorized Official - Last Name:DUMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-217-1791
Mailing Address - Street 1:18813 E 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-2467
Mailing Address - Country:US
Mailing Address - Phone:816-217-1791
Mailing Address - Fax:816-817-0087
Practice Address - Street 1:18813 E 25TH ST S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2467
Practice Address - Country:US
Practice Address - Phone:816-217-1791
Practice Address - Fax:816-817-0087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1740486430Medicaid