MEDICARE: 930, 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	:	1720429582
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	930, LLC

Provider Business Mailing Address
First Line	:	12601 WOODMONT ESTATES CT
Second Line	:
City	:	DES PERES
State	:	MO
Zip	:	63131-2151
Country	:	US
Telephone Number	:	314-406-6136
Fax Number	:

Provider Business Practice Location Address
First Line	:	3003 HIGHWAY 95 STE 39
Second Line	:
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-7896
Country	:	US
Telephone Number	:	314-406-6136
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	NDEYE CEESAY
Credential	:
Telephone Number	:	314-406-6136

Provider Enumeration Date	:	07/09/2013
Last Update Date	:	07/09/2013

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