Provider Demographics
NPI:1447703632
Name:ICAN MISSOURI FOUNDATION
Entity type:Organization
Organization Name:ICAN MISSOURI FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:O'LOUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-269-4549
Mailing Address - Street 1:2000 S HIGHWAY 63
Mailing Address - Street 2:PO BOX 280
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-4532
Mailing Address - Country:US
Mailing Address - Phone:660-269-4549
Mailing Address - Fax:
Practice Address - Street 1:105 NORTH AVE
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-2860
Practice Address - Country:US
Practice Address - Phone:660-269-8875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services