Healthcare Provider Details

I. General information

NPI: 1669891297
Provider Name (Legal Business Name): ABUNDANT CARE CONSUMER DIRECT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 PARK WAY DR
SAINT LOUIS MO
63130-1245
US

IV. Provider business mailing address

1504 PARK WAY DR
SAINT LOUIS MO
63130-1245
US

V. Phone/Fax

Practice location:
  • Phone: 314-449-4946
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SHANDA BONNER
Title or Position: DIRECTOR
Credential:
Phone: 314-449-4946