Basic Information
| Provider Information | |||||||||
| NPI: | 1669829685 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CALO YOUNG ADULT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1810 | ||||||||
| Address2: | |||||||||
| City: | LAKE OZARK | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650491810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737467390 | ||||||||
| FaxNumber: | 5733652224 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 W BOSCAWEN ST | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226014118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407224521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2016 | ||||||||
| LastUpdateDate: | 05/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | SEE | ||||||||
| AuthorizedOfficialFirstName: | SHELLIE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | UTILIZATION REVIEW DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5737467390 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHANGE ACADEMY AT LAKE OF THE OZARKS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.