Healthcare Provider Details

I. General information

NPI: 1326644808
Provider Name (Legal Business Name): PROVIDENT IN HOME SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 N WARSON RD STE 241
SAINT LOUIS MO
63132-1109
US

IV. Provider business mailing address

1 S FLORISSANT RD
FERGUSON MO
63135-2333
US

V. Phone/Fax

Practice location:
  • Phone: 314-736-1919
  • Fax: 314-736-1787
Mailing address:
  • Phone: 314-736-1919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: AIGNER SMITH
Title or Position: DIRECTOR
Credential:
Phone: 314-736-1919