MEDICARE: SUPPORTIVE HEALTHCARE 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

General Provider Information

NPI Number	:	1588096549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPPORTIVE HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	1360 S 5TH ST STE 304
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-2447
Country	:	US
Telephone Number	:	313-606-0228
Fax Number	:	636-724-1691

Provider Business Practice Location Address
First Line	:	1360 S 5TH ST STE 304
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-2447
Country	:	US
Telephone Number	:	314-606-0228
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MARCUS DICKINSON
Credential	:
Telephone Number	:	314-606-0228

Provider Enumeration Date	:	08/01/2013
Last Update Date	:	10/13/2016

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