Provider Demographics
NPI:1548307713
Name:CAMDEN COUNTY SENATE BILL 40 BOARD
Entity type:Organization
Organization Name:CAMDEN COUNTY SENATE BILL 40 BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BOONE
Authorized Official - Middle Name:CALEB
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-317-9233
Mailing Address - Street 1:P.O. BOX 722
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020
Mailing Address - Country:US
Mailing Address - Phone:573-317-9233
Mailing Address - Fax:573-317-9332
Practice Address - Street 1:100 3RD STREET
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020
Practice Address - Country:US
Practice Address - Phone:573-317-9233
Practice Address - Fax:573-317-9332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO156248809Medicaid
MO156234809Medicaid