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SOUTHEAST MISSOURI RESIDENTIAL SERVICES-POPLAR BLUFF
NPI 1124198981
Intermediate Care Facility, Intellectual Disabilities in Poplar Bluff, MO

Active since November 09, 2006CLIA 26D0652182 · Waiver
2351 KANELL BLVD, POPLAR BLUFF, MO 63901(573) 840-9370(573) 840-9373 Get Directions Write a Review

NPPES record last updated: October 27, 2020. Verified against the NPPES registry weekly; last sync: July 26, 2026.

Record update history: Oct 27, 2020, Aug 28, 2019 (2 updates tracked since 2019).

About Southeast Missouri Residential Services-poplar Bluff NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

SOUTHEAST MISSOURI RESIDENTIAL SERVICES-POPLAR BLUFF (NPI 1124198981) is a healthcare organization registered as an intermediate care facility, intellectual disabilities in Poplar Bluff, Missouri and active in the NPI registry since November 2006. The organization holds a CLIA Waiver certificate valid through August 31, 2026 and lists Molly Jane Boeckmann, Director Of Administrative Services, as its authorized official.

NPPES Registry Identity

NPI1124198981
Entity TypeOrganization
Primary Taxonomy315P00000X
Legal Business NameSTATE OF MISSOURI
Location Address2351 KANELL BLVDPoplar Bluff, MO 63901-4035
Mailing AddressPo Box 687Jefferson City, MO 65102-0687 · (573) 751-3398 · Fax (573) 526-4560
Phone(573) 840-9370
Fax(573) 840-9373
Organization SubpartYes
Authorized OfficialMolly Jane BoeckmannDirector Of Administrative Services · (573) 751-4055
Enumeration DateNovember 9, 2006
Last NPPES UpdateOctober 27, 20202 updates tracked since enumeration
NPPES CertifiedOctober 27, 2020
✔ NPI 1124198981 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyIntermediate Care Facility, Intellectual DisabilitiesNursing & Custodial Care Facilities
Taxonomy Code315P00000X
License✔ Licensed in MO · EXEMPT
Definition

An intermediate care facility providing services for individuals with intellectual disabilities.

2351 KANELL BLVD, Poplar Bluff, MO 63901
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Other Names 1

Doing Business AsSoutheast Missouri Residential Services-poplar Bluff

Other Identifiers 1

Medicaid051793107MO

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 26D0652182

Southeast Missouri Residential Service · Poplar Bluff, MO
Active · expires Aug 31, 2026
CLIA Number26D0652182
Laboratory TypeIntermediate Care Facility For Mentally Retarded
Certificate Effective DateSeptember 1, 2024
Certificate Expiration DateAugust 31, 2026
Laboratory DirectorRebecca Hann
Laboratory Phone(573) 840-9370
Laboratory LocationSoutheast Missouri Residential Service2351 Kanell Blvd, Poplar Bluff, MO 63901
CLIA data matches this NPI record on: Address Name Phone
This certificate is issued to a laboratory to perform only waived tests.

Other Providers at the Same Location NPPES 5

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

STATE OF MISSOURI
Case Management
2351 KANELL BLVD
POPLAR BLUFF, MO 63901
Butler County (573) 840-9300
STATE OF MISSOURI
Day Training, Developmentally Disabled Services
2351 KANELL BLVD
POPLAR BLUFF, MO 63901
Butler County (573) 840-9300
SOUTHEAST MISSOURI RESIDENTIAL SERVICES
Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
2351 KANELL BLVD
POPLAR BLUFF, MO 63901
Butler County (573) 840-9300
STATE OF MISSOURI
Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
2351 KANELL BLVD
POPLAR BLUFF, MO 63901
Butler County (573) 840-9374
STATE OF MISSOURI
Family Medicine
2351 KANELL BLVD
POPLAR BLUFF, MO 63901
Butler County (573) 840-9370

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is State Of Missouri's NPI number?

The NPI number for State Of Missouri is 1124198981. It was assigned to this organization in the NPPES registry on November 9, 2006. The provider is doing business as Southeast Missouri Residential Services-Poplar Bluff.

Where is State Of Missouri located?

State Of Missouri is located at 2351 Kanell Blvd, Poplar Bluff, MO 63901. The listed phone number is (573) 840-9370.

What is State Of Missouri's specialty?

The primary specialty registered for this NPI is Intermediate Care Facility, Intellectual Disabilities with taxonomy code 315P00000X.

Does State Of Missouri hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 26D0652182) is associated with this NPI, valid through August 31, 2026. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for State Of Missouri was last updated on October 27, 2020. NPI Profile syncs with the weekly NPPES data releases published by CMS.