Provider Demographics
NPI:1033511761
Name:SEMO ALLIANCE FOR DISABILITY INDEPENDENCE
Entity type:Organization
Organization Name:SEMO ALLIANCE FOR DISABILITY INDEPENDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUDERMUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-651-6464
Mailing Address - Street 1:1913 RUSMAR ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-7623
Mailing Address - Country:US
Mailing Address - Phone:573-651-6464
Mailing Address - Fax:573-651-6565
Practice Address - Street 1:1913 RUSMAR ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-7623
Practice Address - Country:US
Practice Address - Phone:573-651-6464
Practice Address - Fax:573-651-6565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
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
MO1760576425Medicaid
MO1932231651Medicaid