Provider Demographics
NPI:1184754046
Name:MAURIZI ISL HOME
Entity type:Organization
Organization Name:MAURIZI ISL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MAURIZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-256-1296
Mailing Address - Street 1:2015 WOODHOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-0909
Mailing Address - Country:US
Mailing Address - Phone:573-256-1296
Mailing Address - Fax:573-256-1016
Practice Address - Street 1:2015 WOODHOLLOW DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-0909
Practice Address - Country:US
Practice Address - Phone:573-256-1296
Practice Address - Fax:573-256-1016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO856917109320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO856917109Medicaid