Healthcare Provider Details

I. General information

NPI: 1124233770
Provider Name (Legal Business Name): HOME AWAY FROM HOME HEALTHCARE FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13323 CRYSTAL AVE
GRANDVIEW MO
64030-3338
US

IV. Provider business mailing address

2004 SW KLINE AVE
LEES SUMMIT MO
64082-4064
US

V. Phone/Fax

Practice location:
  • Phone: 816-525-2470
  • Fax:
Mailing address:
  • Phone: 816-525-2470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANGELINA MARIE REYNOLDS
Title or Position: CO-OWNER
Credential:
Phone: 816-525-2470