=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235791682
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKYLIGHT HOME CARE SERVICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2019
-----------------------------------------------------
Last Update Date | 07/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 N WARSON RD STE 122
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63132-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-731-6444
-----------------------------------------------------
Fax | 314-731-6126
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 N WARSON RD STE 122
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63132-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-731-6444
-----------------------------------------------------
Fax | 314-731-6126
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | SHANTELL MCDONALD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-731-6444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------