MEDICARE: QUEEN HOME CARE, 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	253Z00000X	In Home Supportive Care Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	23380446	OTHER	MO	BUSINESS TAX REGISTRATION - MO DEPARTMENT OF REVENUE

General Provider Information

NPI Number	:	1528598406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUEEN HOME CARE, LLC

Provider Business Mailing Address
First Line	:	4333 MANCHESTER AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-2137
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4333 MANCHESTER AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-2137
Country	:	US
Telephone Number	:	314-303-0433
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MAHMOOD ABOSARA
Credential	:
Telephone Number	:	314-303-0433

Provider Enumeration Date	:	06/14/2017
Last Update Date	:	06/14/2017

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Directions to “QUEEN HOME CARE, LLC ” Practice Location

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