Provider Demographics
NPI:1144556572
Name:DEVELOPMENTAL DISABILITY SERVICES OF JACKSON COUNTY - EITAS
Entity type:Organization
Organization Name:DEVELOPMENTAL DISABILITY SERVICES OF JACKSON COUNTY - EITAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:HASELTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-363-2000
Mailing Address - Street 1:8508 HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64138-2762
Mailing Address - Country:US
Mailing Address - Phone:816-363-2000
Mailing Address - Fax:816-363-1755
Practice Address - Street 1:8508 HILLCREST RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64138-2762
Practice Address - Country:US
Practice Address - Phone:816-363-2000
Practice Address - Fax:816-363-1755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO853541506Medicaid