Healthcare Provider Details

I. General information

NPI: 1871041632
Provider Name (Legal Business Name): MY MOTHERS WISH HOME HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7004 PLYMOUTH AVE
SAINT LOUIS MO
63130-2451
US

IV. Provider business mailing address

7004 PLYMOUTH AVE
SAINT LOUIS MO
63130-2451
US

V. Phone/Fax

Practice location:
  • Phone: 314-363-1726
  • Fax:
Mailing address:
  • Phone: 314-363-1726
  • 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 Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name: TRACEY ELAINE SIMMONS
Title or Position: HEALTHCARE PROVIDER
Credential:
Phone: 314-363-1726