Provider Demographics
NPI:1245300375
Name:STATE OF MISSOURI
Entity type:Organization
Organization Name:STATE OF MISSOURI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:ZENGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-592-4000
Mailing Address - Street 1:505 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-1703
Mailing Address - Country:US
Mailing Address - Phone:573-592-4000
Mailing Address - Fax:573-592-2570
Practice Address - Street 1:505 E 5TH ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-1703
Practice Address - Country:US
Practice Address - Phone:573-592-4000
Practice Address - Fax:573-592-2570
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MISSOURI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-08
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506138205Medicaid