Provider Demographics
NPI:1053450643
Name:BRECKENRIDGE R-I SCHOOL DISTRICT
Entity type:Organization
Organization Name:BRECKENRIDGE R-I SCHOOL DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLENIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-644-5715
Mailing Address - Street 1:400 W COLFAX ST
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MO
Mailing Address - Zip Code:64625-9608
Mailing Address - Country:US
Mailing Address - Phone:660-544-5715
Mailing Address - Fax:660-644-5710
Practice Address - Street 1:400 W COLFAX ST
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MO
Practice Address - Zip Code:64625-9608
Practice Address - Country:US
Practice Address - Phone:660-544-5715
Practice Address - Fax:660-644-5710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251300000XAgenciesLocal Education Agency (LEA)
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506166305Medicaid