MEDICARE: 1ST HOME AWAY FROM HOME IHS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1376281519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1ST HOME AWAY FROM HOME IHS LLC

Provider Business Mailing Address
First Line	:	4735 PLOVER AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63120-1822
Country	:	US
Telephone Number	:	314-479-1673
Fax Number	:

Provider Business Practice Location Address
First Line	:	4735 PLOVER AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63120-1822
Country	:	US
Telephone Number	:	314-479-1673
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	LAWANDA GUESRT
Credential	:
Telephone Number	:	314-479-1673

Provider Enumeration Date	:	05/26/2022
Last Update Date	:	05/26/2022

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