Healthcare Provider Details

I. General information

NPI: 1396374385
Provider Name (Legal Business Name): MAGDALA HOME HEALTH CARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 07/08/2023
Certification Date: 07/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 BISMARK AVE
SAINT LOUIS MO
63119-1524
US

IV. Provider business mailing address

2536 HIDDEN MEADOW LN
BALLWIN MO
63021-7824
US

V. Phone/Fax

Practice location:
  • Phone: 314-814-1869
  • Fax:
Mailing address:
  • Phone: 314-814-1869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MARY MAGDALENE ADOU GBOUGBO
Title or Position: OWNER
Credential:
Phone: 314-814-1869