Provider Demographics
NPI:1063659019
Name:MICHAEL W. PRENGER FAMILY CENTER
Entity type:Organization
Organization Name:MICHAEL W. PRENGER FAMILY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COURT ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:COUTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-636-5177
Mailing Address - Street 1:400 STADIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-2811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-2811
Practice Address - Country:US
Practice Address - Phone:573-636-5177
Practice Address - Fax:573-634-5162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children