Healthcare Provider Details

I. General information

NPI: 1396626842
Provider Name (Legal Business Name): ULTIMATE DREAM HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 WASHINGTON AVE STE 408
SAINT LOUIS MO
63103-1917
US

IV. Provider business mailing address

1409 WASHINGTON AVE STE 408
SAINT LOUIS MO
63103-1917
US

V. Phone/Fax

Practice location:
  • Phone: 314-410-9117
  • Fax:
Mailing address:
  • Phone: 314-410-9117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: TAIYONNA BLACKMON
Title or Position: OWNER
Credential: LPN
Phone: 314-410-9117