Healthcare Provider Details

I. General information

NPI: 1841698388
Provider Name (Legal Business Name): WALLACE FAMILY IN HOME HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2014
Last Update Date: 12/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3937 PARK AVE PARK WAREHOUSE
SAINT LOUIS MO
63110-2317
US

IV. Provider business mailing address

6530 JULIAN AVE
SAINT LOUIS MO
63133-1410
US

V. Phone/Fax

Practice location:
  • Phone: 314-713-1105
  • Fax: 314-754-9969
Mailing address:
  • Phone: 314-713-1105
  • Fax: 314-754-9969

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 Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: BRITTANY JACKSON
Title or Position: CEO
Credential:
Phone: 314-713-1105