Healthcare Provider Details

I. General information

NPI: 1588349245
Provider Name (Legal Business Name): MRS OCTAVIA INHOME HEALTH CARE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 01/20/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 GOODFELLOW BLVD APT A1516
SAINT LOUIS MO
63112-3828
US

IV. Provider business mailing address

1516 GOODFELLOW BLVD APT A
SAINT LOUIS MO
63112-3828
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4209
  • Fax: 314-226-4500
Mailing address:
  • Phone: 314-260-9106
  • Fax: 557-467-2616

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 Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: DEBRA EDWARDS
Title or Position: OWNER
Credential:
Phone: 314-260-9106