Healthcare Provider Details

I. General information

NPI: 1558815894
Provider Name (Legal Business Name): SACRED HEART CONSUMER DIRECTED SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2013 HOMEFIELD RIDGE DR
O FALLON MO
63366-4752
US

IV. Provider business mailing address

2013 HOMEFIELD RIDGE DR
O FALLON MO
63366-4752
US

V. Phone/Fax

Practice location:
  • Phone: 314-839-3359
  • Fax:
Mailing address:
  • Phone: 314-839-3359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number16-000066
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number16-000066
License Number StateMO

VIII. Authorized Official

Name: LATINA BERRYHILL
Title or Position: DIRECTOR
Credential:
Phone: 314-445-4247